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: 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
No charge
No 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% 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%
$20 Copay
Not covered
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 Transportation
No charge
No charge
Inpatient Hospitalization & Professional Service
After Deductible you pay 20% After Deductible you pay 20% 20% ($15 min, $30 max) 30% ($30 min, $60 max) 40% ($60 min, $120 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 Drugs
Preferred Brand Drugs
Non-Preferred Brand Drugs
Home Delivery Pharmacy (30-Day Supply):
50% ($80 min, $160 max)
After Deductible you pay 20%
Specialty Drugs
Not covered
Not covered
Home Delivery Pharmacy (90-Day Supply):
20% ($30 min, $60 max) 30% ($60 min, $120 max) 40% ($120 min, $240 max)
After Deductible you pay 20% After Deductible you pay 20% After Deductible you pay 20%
Generic Drugs
Not covered
Not covered
Preferred Brand Drugs
Not covered
Not covered
Non-Preferred Brand Drugs
Not covered
Not covered
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