COMPARISON OF MEDICAL + PRESCRIPTION DRUG BENEFITS AT-A-GLANCE
C H O I C E F U N D H R A P L A N
C H O I C E F U N D H S A P L A N
BENEFIT
IN-NETWORK
IN-NETWORK
OUT-OF-NETWORK
OUT-OF-NETWORK
M E D I C A L B E N E F I T S
Annual Deductible
$2,000 $4,000
$4,000 $8,000
$1,250 $1,250/$2,500
$2,500 $2,500/$5,000
Individual Individual (Embedded)/Family Out-of-Pocket Maximum includes deductible and coinsurance Individual Individual (Embedded)/Family Co-insurance Preventive Care Cigna Telehealth Connection Services (MDLIVE® or Amwell®)
$4,000 $7,350/$8,000 Plan pays 80% You pay 20%
$8,000 $16,000
$3,750 $3,750/$7,500 Plan pays 80% You pay 20%
$7,500 $7,500/$15,000 Plan pays 50% You pay 50%
Plan pays 50% You pay 50%
No Charge
Not Covered
No Charge
Not Covered
You pay $42. After Deductible, you pay 20%
No Charge
Not Covered
Not Covered
After Deductible, you pay 50% After Deductible, you pay 50%
After Deductible, you pay 20% After Deductible, you pay 20% After Deductible, you pay 20% After Deductible, you pay 20% After Deductible, you pay 20% After Deductible, you pay 20% After Deductible, you pay 20% After Deductible, you pay 20% After Deductible, you pay 20% After Deductible, you pay 20% After Deductible, you pay 20% After Deductible, you pay 20% After Deductible, you pay 20% After Deductible, you pay 20% After Deductible, you pay 20%
After Deductible, you pay 50% After Deductible, you pay 50% After Deductible, you pay 20% After Deductible, you pay 20% After Deductible, you pay 20% After Deductible, you pay 50% After Deductible, you pay 50% After Deductible, you pay 50% After Deductible, you pay 50% After Deductible, you pay 50% After Deductible, you pay 50%
Primary Care Physician (PCP) Office Visit
$30 Copay
Specialist Office Visit
$40 Copay
Urgent Care
$50 Copay
$50 Copay
After Deductible, you pay 20%
After Deductible, you pay 20%
Emergency Room
Emergency Medical Transportation
No Charge
No Charge
Inpatient Hospitalization & Professional Services Out Patient Facility & Professional Services
After Deductible, you pay 50% After Deductible, you pay 50%
After Deductible, you pay 20% After Deductible, you pay 20%
r E T A I L P H A R M A C Y ( 3 0 - D A Y S U P P L Y )
20% ($10 min, $20 max) 30% ($25 min, $50 max) 40% ($50 min, $100 max) 50% ($75 min, $150 max) 20% ($25 min, $50 max) 30% ($50 min, $100 max) 40% ($100 min, $200 max) 50% ($150 min, $300 max)
After Deductible, you pay 50% After Deductible, you pay 50% After Deductible, you pay 50% After Deductible, you pay 50%
Generic Drugs
Formulary Brand Drugs
Non-Formulary Brand Drugs Specialty Drugs
H O M E D E L I V E R Y P H A R M A C Y ( 9 0 - D A Y S U P P L Y )
Generic Drugs
Not Covered
Not Covered
Formulary Brand Drugs
Not Covered
Not Covered Not Covered Not Covered
Non-Formulary Brand Drugs Specialty Drugs
Not Covered Not Covered
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