Benefit Guide - Stripes

MEDICAL BENEFITS

OPEN ACCESS PLUS IN-NETWORK PLAN

OPEN ACCESS PLUS IN-NETWORK PLAN W/NONSTOP HEALTH

BENEFIT

IN-NETWORK

MEMBER RESPONSIBILITY

Annual Deductible

Individual: $6,300; Family: $12,600

Individual: $0; Family: $0

Out-of-Pocket Maximum

Individual: $9,100; Family: $18,200

Individual: $0; Family: $0

Coinsurance

Cigna Pays: 70% Employee Pays: 30%

0%

Preventive Care Adult Preventive Care Adult Annual Physical Exam Well-Child Care

No Charge

$0

Inpatient Care Room and Board

70% coinsurance after deductible

$0

Outpatient Care Primary care physician office visits Specialist office visits Virtual Visits Outpatient facility surgery Lab & X-Ray Advanced Radiology (CT/PET Scan, MRI - Preauthorization required)

70% coinsurance (deductible waived) 70% coinsurance (deductible waived) 70% coinsurance (deductible waived) 70% coinsurance after deductible 70% coinsurance after deductible 70% coinsurance after deductible

$0 $0 $0 $0 $0 $0

Emergency Care Ambulance when medically necessary At hospital emergency room Urgent Care Maternity Care Office Visits Hospital services for mother and child Mental Health/Substance Abuse Inpatient Outpatient

70% coinsurance after deductible $100 copay after deductible 70% coinsurance after deductible

$0 $100 copay $0

70% coinsurance (deductible waived) 70% coinsurance after deductible

$0 $0

70% coinsurance after deductible 70% coinsurance (deductible waived)

$0 $0

Prescription Drug Deductible

None

$0

Retail Pharmacy (30 day supply) Generic/Preferred Brand/Non-Preferred Brand

$10/$30/$60 (deductible waived)

$0

Mail Order (90 day supply) Generic/Preferred Brand/Non-Preferred Brand

$30/$90/$180 (deductible waived)

$0

SALARY BANDED CONTRIBUTIONS

Bi-weekly Contributions

$27,300 - $50,999

$51,000 - $70,999

$71,000 - $90,999

$91,000+

Employee

$58.58

$73.22

$91.52

$109.83

Employee & Spouse

$117.15

$146.44

$183.05

$219.66

Employee & Child(ren)

$99.58

$124.47

$155.59

$186.71

Family

$166.94

$208.67

$260.84

$313.01

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