LM_SW_Benefits Guide 2024

Medical Benefits

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HEALTH SAVINGS ACCOUNT (HSA) PLAN

BENEFIT

IN-NETWORK Individual: $1,750 Family: $3,500 Individual: $4,500 Family: $9,000

OUT-OF-NETWORK

Annual Deductible

Individual: $5,250 Family: $10,500 Individual: $12,000 Family: $24,000

Out-of-Pocket Maximum (includes deductibles, copays, and coinsurance)

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Lifetime Maximum

Unlimited

Unlimited

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

100% 100% 100%

70% after deductible 70% after deductible 100%, deductible waived

Outpatient Care Primary Care Physician Office Visits Specialist Office Visits Outpatient Facility Surgery Outpatient Lab & X-Ray Initial visit and all subsequent visits

80% after deductible 80% after deductible 80% after deductible

60% after deductible 60% after deductible 60% after deductible

CIGNA Open Access Plus Network or call 800.CIGNA24 (800.244.6224)

80% after deductible 80% after deductible

60% after deductible 60% after deductible

Hospital Care

Emergency Care At hospital emergency room

80% after deductible

80% after deductible

PRICE ASSURE (POWERED BY GOODRX) Cigna’s partnership with GoodRx may allow members to receive the lowest prescription cost when filling eligible generic non-specialty prescriptions at participating pharmacies. The price you pay will count towards your deductible and out-of pocket maximum. Employer contributions to HSA for January 1, 2024 First year participants will receive $500/$1,000 (Individual / All Other Tiers) Second year participants will receive $250/$500 (Individual / All Other Tiers) Participants with three years or more will receive $250/$500 (Individual / All Other Tiers)

Mental Health Inpatient Outpatient

80% after deductible 80% after deductible

60% after deductible 60% after deductible

Prescription Drugs Deductible

Subject to plan deductible

Retail Pharmacy (30-day supply) Generic/Preferred/Non-Preferred Mail Order (90-day supply) Generic/Preferred/Non-Preferred

80% after deductible

In-Network Only

Texas legislation requires insured medical plans to extend the right for an employee to choose not to pay for coverage of elective abortions if such coverage is contrary to moral, ethical, or religious beliefs. The plan offered includes the coverage of elective abortions. You have the right to choose a health plan with or without coverage for elective abortions. Rates for enrollees that choose to decline a plan providing elective abortion coverage will be slightly lower than the rates offered to enrollees that choose a plan that covers elective abortion. Covered expenses count towards both your in-network and out-of-network deductibles and out-of-pocket maximums. Only the amount you pay for in-network deductible and out-of-pocket maximums count towards in-network. Out-of-network deductibles and out-of-pocket maximums both count towards in-network. This means that if you have met your in-network deductible of $1,750 and you choose to visit an out-of-network provider, you have a separate out-of-network deductible of $5,250 per individual. 80% after deductible In-Network Only Cigna’s HSA family plan deductible is met through a total of all family members’ out-of-pocket expenses without single amount limits. Once the HSA family deductible is met, all family members’ are covered by the plan coinsurance until the out-of-pocket maximum is satisfied.

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