Medical Benefits Comparison
Dental Benefits
Medical Benefits 1
Option 1: HSA Plan
Option 2: PPO Plan
Cigna | 1-800-244-6224 | www.mycigna.com | Group Number: 3332287
Deductible: Individual / Family
$3,000 / $6,000 (Shared) 2
$2,000 / $4,000 (Embedded) 3
Your PIH dental benefits are administered by Cigna.
Out-of-Pocket Maximum : Individual / Family
$3,000 / $6,000
$3,000 / $6,000
Dental Weekly Premiums Employee Only
Base Plan
Buy-Up Plan
Services Received at a Practicioner's Office
Dental Plan Benefits
Base Plan Buy-Up Plan
$2.43 $3.71
Individual / Family Deductible Calendar Year Maximum (per enrolled person) Preventive Services (Deductible does not apply)
$50 / $150 $25 / $75
Preventive Care
100%
100%
EMP + Spouse $5.35 $8.16 EMP + Child(ren) $4.87 $7.43 EMP + Family $6.81 $10.39
Office Visit For sick visits, please consider Teladoc first
$1,500
$2,500
100% after deductible
80% after deductible
Services Received at a Facility Emergency Room
100%
100%
100% after deductible
80% after deductible
You can visit any dentist that you choose. However, if your provider is not in- network, they may charge more than the usual and customary rate, and you may be responsible for the additional charges. To find an in-network provider, go to the online directory at www.cigna.com. Please be sure to carefully review the online directory or call Cigna to confirm that your provider participates in the network.
80% after deductible 60% after deductible
80% after deductible 70% after deductible
Basic Services
Most Other Services
100% after deductible
80% after deductible
Pharmacy
Major Restorative Services
Retail Preventive Generics Generics / Preferred Brand/Non-Preferred Brands Mail Order 4 Preventive Generics Generics/Preferred Brand/Non-Preferred Brands
Orthodontic Services (Deductible does not apply) Orthodontic Lifetime Maximum (Covers children up to age 19, lifetime max per child)
Plan pays 100% 100% after deductible
$10 / $35 / $60
50%
50%
$1,500
$2,500
Plan pays 100% 100% after deductible
3x Retail copay
Specialty Drugs
100% after deductible
N/A / $35 / $60
All benefits shown In-Network
Vision Benefits
1. See your Evidence of Coverage for Out-of-Network Benefits, prior authorization, visit limits and more. 2. Shared Family Deductible - entire family deductible must be met before the plan will pay. 3. Embedded Deductible - each individual is only responsible for the individual deductible amount before the plan will pay (maximum two deductibles).
Cigna | 1-800-244-6224 | www.mycigna.com | Group Number: 3332287
Health Savings Account
Your PIH vision benefits are administered by Cigna . When using in-network providers, this PPO plan covers most exams, eyeglasses, and medically necessary contacts in full. Discounts are available for upgrades on covered frames and lenses. Should you choose to see an out-of-network provider, Cigna will reimburse you up to a specified amount. The out-of-network reimbursement schedule is summarized in the Vision Plan Benefits table below.
Vision Weekly Premiums
Employee Only EMP + Spouse EMP + Child(ren)
$1.59 $3.20 $3.18 $5.05
HSA Bank | 1-855-731-5225
If you are enrolled in the HSA Plan, you are eligible to participate in a Health Savings Account (HSA) through HSA Bank . The HSA is established to pay for future qualified medical, dental and vision expenses that are incurred by you or your dependents enrolled in the plan. PIH contributes to the HSA quarterly on your be - half, so it is to your advantage to make the most of your HSA. You must contribute a minimum of $5 per week in order to receive the PIH contri- bution. You may make tax-free payroll contributions to the account to pay for subsequent future quali-
EMP + Family
Annual Maximum Contributions to your HSA
Total Amount You May Contribute
IRS Annual Maximum Contribution
Vision Benefits
In-Network Out-of-Network
PIH's Contribution
To find an in-network provider or surgery center, review out-of- network benefits, and other plan details, go to the online directory at cigna.vsp.com and click on the “Find a Cigna Vision Network Eye Care Professional” button to begin your search. Please be sure to care - fully review the online directory or call Cigna to confirm that your pro - vider participates in the network.
Vision Exam
$10 Copay
$45 Allowance
Up to $80 Allowance depending on type
$225 Quarterly, $900 Annually $400 Quarterly. $1,600 Annually $400 Quarterly. $1,600 Annually $500 Quarterly, $2,000 Annually
Lenses (once per year) Single / Bifocal / Trifocal / Lenticular
$2,950
Employee Only
$3,850
$10 Copay / covered in full
$6,150
Emp + Spouse
$7,750
Frames (once every 2 years)
$140 Allowance
$77 Allowance
$6,150
Emp + Child(ren)
$7,750
Contacts in lieu of eyeglasses (once per year) Medically Necessary Elective
$10 Copay
$5,750
Emp + Family
$7,750
Covered in full Up to $150
$210 Allowance $120 Allowance
fied medical expenses. Your contributions to the HSA will be payroll deducted and the funds deposited into your HSA. You may change the amount you contribute to your HSA at any time during the plan year. When a qualified expense is incurred, you simply use your HSA debit card or request reimbursement for the expense from the custodial account. Unused account dollars are yours to keep, even if you retire or leave the company. Also, if you are 55 years of age or older you may contribute an additional $1,000 catch-up contribu - tion to your HSA.
4
5
Made with FlippingBook Annual report maker