Page Comparison

In-NetworkOut-of-Network

Comparative Features

HDHP/HSA OptionOAP/PPO Option

High Deductible Health Plan (HDHP) Benefits

Covered Employees Elect Either a Companion HSA or HRA

In-Network

Out-of-Network

Deductible


Individual	$2,

000

500	N/A (In- and out-of-network Deductible cross-accumulate

$750

$950

Family

$4

$5,000

$2,250

$2,850

Out-of-Pocket (OOP) Maximum

Individual

$4,000

N/A (In- and out-of-network Deductible

cross-accumulate

$2,750$10,750 Includes the deductibleSPU HSA

Family

$8,000

$8,250$32,250

*within Family coverage, Individual Max also applies	$4,000
	The OOP max includes deductible, coinsurance, and any other covered medical expenses
SPU Funding to offset Deductible for HSA Plan	Individual

HSA Plan: Up to $1,

008 ($84 per month of participation)

Not available

SPU HSA

608, (assuming 12-months of participation and employee meets full dollar-for-dollar match)

Family HSA Plan: Up to $3,016 (assuming 12-months of participation and employee meets full dollar-for-dollar match)

SPU Funding to offset Deductible for

Family

Up to $2,016 ($168 per month of participation

Not available

HRA Plan

Individual HRA Plan: SPU makes $1,008 available for reimbursement

Family HRA Plan: SPU makes $2,016 available for reimbursement

Coinsurance - You pay:

10%40%

	10%	40%
Office

Visit

Visits

No copay; You pay 10% AFTER Deductible

No copay; You pay 40% AFTER Deductible

$25 copay; deductible waived, no coinsurance

No copay; You pay 40% AFTER Deductible

Preventive Care –

Routine Physicals (Adult exams)
Routine Well-Child Exams
Routine Mammograms
Routine DRE/Prostate Antigen Test/Exam for males
Routine Colorectal Cancer Screening

Covered 100%; deductible waived

Diagnostic mammograms covered under Diagnostic Lab/

Xray

Covered 100%; deductible waived

Diagnostic mammograms covered the same as routine mammograms

X-ray

In-Network Diagnostic Lab/

Xray

X-ray Outpatient

No copay; You pay 10% AFTER Deductible

No copay; You pay 40% AFTER Deductible

No copay; You pay 10% AFTER Deductible

No copay; You pay 40% AFTER Deductible

Urgent Care Provider (both In and Out-of-Network)

No copay; You pay 10% AFTER Deductible

Deductible applies after $25 copay; then plan pays 100%

Emergency Room (both In and Out-of-Network)

No copay; You pay 10% AFTER Deductible

Deductible applies after $100 copay (waived if admitted); then plan pays 90%

Ambulance (both In and Out-of-Network)

No copay; You pay 10% AFTER Deductible

	No copay; You pay 10% AFTER Deductible
Hospital - Inpatient (both In and Out-of-Network)	No copay; You pay 10% AFTER Deductible

No copay; You pay 10% AFTER Deductible

Prescription Drugs

In-Network - Pharmacy – Retail

10% (generic) /20% (preferred brand)/30% (non-preferred brand) AFTER Deductible

Full cost of prescriptions accumulate towards the deductible
Specific Generic Preventive drugs covered at 100% with deductible waived
Other Brand-Name Preventive drugs require you pay 20% or 30% with deductible waived

Not covered

$10 (generic) /$25 (preferred brand) /$45 (non-preferred brand)

Co-pays count toward out-of-pocket maximum
Deductible does not apply
$5 copay for Specific Generic Preventive drugs

Not covered

Pharmacy –

Cigna

Mail Order Drug (90 day supply)

10% (generic) /20% (preferred brand) /30% non-preferred brand) AFTER Deductible

Full cost of prescriptions accumulate towards the deductible
Specific Generic Preventive drugs covered at 100%, deductible waived
Other Brand-Name Preventive drugs require you pay 20% or 30% with deductible waived
Shop pharmacies for lowest price

Not covered

$20 (generic) /$50 (preferred brand) /$90 (non-preferred brand)

Deductible does not apply
Co-pays count toward out-of-pocket maximum
$10 copay for Specific Generic Preventive drugs

Not covered

Versions Compared

Old Version 1

New Version Current

Key