fƷƱǘƫƎǯ ޘ ȣƷȪƫȣǘȠȴǘȅǻ $ȣȽNj ƷǻƷ̯ȴȪƎȴƎ=ǯƎǻƫƷ
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 Out-of-Pocket Maximum (copay, deductible & coinsurance) Individual Individual (Embedded)/Family
$1,500 $1,500/$3,000
$3,000 $3,000/$6,000
$2,000 $4,000
$4,000 $8,000
$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
No covered
Cigna Vir tual Care (Telehealth) Services (MDLive) Primary Care Physician (PCP) Office Visit
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%
Not covered
No charge
Not covered
After Deductible you pay 50% After Deductible you pay 50%
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%
$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 Transpor tation
No charge
No charge
Inpatient Hospitalization & Professional Service
After Deductible you pay 20% After Deductible you pay 20% 20% ($10 min, $20 max) 30% ($25 min, $50 max) 40% ($50 min, $100 max)
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%
Outpatient Facility & Professional Services
Retail Pharmacy (30-Day Supply): Generic Medications
Preferred Brand Medications Non-Preferred Brand Medications
Home Delivery Pharmacy (30-Day Supply): Specialty Medications Home Delivery Pharmacy (90-Day Supply): Generic Medications
50% ($75 min, $150 max)
After Deductible you pay 20%
Not covered
Not covered
20% ($25 min, $50 max) 30% ($50 min, $100 max) 40% ($100 min, $200 max)
After Deductible you pay 20% After Deductible you pay 20% After Deductible you pay 20%
Not covered
Not covered
Preferred Brand Medications Non-Preferred Brand Medications
Not covered
Not covered
Not covered
Not covered
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