Choice Fund HRA Plan
Choice fund HSa plan
Benefit
In-Network
Out-of-network
In-network
Out-of-network
Medical benefits Annual Deductible
Individual Individual (Embedded)/Family
$1,500 $1,500/$3,000
$3,000 $3,000/$6,000
$2,000 $4,000
$4,000 $8,000
Out-of-Pocket Maximum includes copays, deductible and coinsurance
Individual Individual (Embedded)/Family
$4,000 $4,000/$8,000 Plan pays 80% You pay 20%
$8,000 $8,000/$16,000 Plan pays 50% You pay 50%
$5,000 $6,900/$10,000 Plan pays 80% You pay 20%
$10,000 $13,800/$20,000
Plan pays 50% You pay 50%
Co-insurance
Preventive Care
No Charge
Not Covered
No Charge
Not Covered
Cigna Telehealth Connection Services (MDLIVE® or Amwell®)
You pay $45-$49. 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 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%
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
After Deductible, you pay 20% After Deductible, you pay 20%
After Deductible, you pay 50% After Deductible, you pay 50%
Outpatient Facility & Professional Services
Retail Pharmacy (30-Day Supply)
After Deductible, you pay 50% After Deductible, you pay 50% After Deductible, you pay 50%
Generic Medications
20% ($10 min, $20 max)
Preferred Brand Medications
30% ($25 min, $50 max)
Non-Preferred Brand Medications
40% ($50 min, $100 max)
Home delivery pharmacy (30-day supply)
50% ($150 min, $300 max)
After Deductible, you pay 20%
Not Covered
Not Covered
Specialty Medications
Home delivery pharmacy (90-day supply)
After Deductible, you pay 20% After Deductible, you pay 20% After Deductible, you pay 20%
20% ($25 min, $50 max)
Generic Medications
Not Covered
Not Covered
30% ($50 min, $100 max)
Preferred Brand Medications
Not Covered
Not Covered
40% ($100 min, $200 max)
Non-Preferred Brand Medications
Not Covered
Not Covered
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