Medical + Prescription Drug Benefits At-a-Glance
Choice Fund HRA Plan
Choice Fund HSA Plan
Benefit
In-Network
Out-of-Network
In-Network
Out-of-Network
Medical Benefits through Cigna: Annual Deductible Individual Individual (Embedded)/Family Out-of-Pocket Maximum (copay, deductible & coinsurance) Individual Individual (Embedded)/Family
$1,750 $1,750/$3,500
$3,500 $3,500/$7,000
$2,250 $4,500
$4,500 $9,000
$4,250 $4,250/$8,500 Plan pays 80% You pay 20%
$8,500 $8,500/$17,000 Plan pays 50% You pay 50%
$5,250 $8,000/$10,500 Plan pays 80% You pay 20%
$10,500 $16,000/$21,000 Plan pays 50% You pay 50%
Coinsurance
Preventive Care
No charge
Not covered
Not charge
Not covered
Cigna Virtual 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% You pay 20% (Deductible does not apply) 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
$20 Copay
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% You pay 20% (Deductible does not apply) After Deductible you pay 20% After Deductible you pay 50% After Deductible you pay 50%
$30 Copay
$40 Copay
Specialist Office Visit
$50 Copay
$50 Copay
Urgent Care
You pay 20% (Deductible does not apply)
You pay 20% (Deductible does not apply)
Emergency Room
Emergency Medical Transportation
No charge
No charge
Inpatient Hospitalization & Professional Service
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 Benefits through Express Scripts (30-Day Supply):
20% ($15 min, $30 max) 30% ($30 min, $60 max) 40% ($60 min, $120 max) 50% ($80 min, $160 max)
Generic Drugs
Not covered
Not covered
Preferred Brand Drugs
Not covered
Not covered
Non-Preferred Brand Drugs
Not covered
Not covered
Speciality Drugs
Not covered
Not covered
Home Delivery Pharmacy Benefits through Express Scripts (90-Day Supply):
20% ($30 min, $60 max) 30% ($60 min, $120 max) 40% ($120 min, $240 max)
Generic Drugs
Not covered
Not covered
Preferred Brand Drugs
Not covered
Not covered
Non-Preferred Brand Drugs
Not covered
Not covered
23
Made with FlippingBook interactive PDF creator