Plan Comparison of Coverage

Comparative Features	HDHP/HSA Option
Comparative Features	In-Network	Out-of-Network
Deductible
Individual	$2,000	N/A (In- and out-of-network Deductible cross-accumulate
Family	$4,000	N/A (In- and out-of-network Deductible cross-accumulate
Out-of-Pocket (OOP) Maximum
Individual	$3,425	N/A (In- and out-of-network Deductible cross-accumulate
Family	$6,850	N/A (In- and out-of-network Deductible cross-accumulate
	Includes the deductible
SPU HSA Funding to offset Deductible for Individual	Up to $1,008 ($84 per month of participation)
SPU HSA Funding to offset Deductible for Family	Up to $2,016 ($168 per month of participation)
Coinsurance - You pay:	10%	40%
Office Visit	No copay; You pay 10% AFTER Deductible	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
In-Network Diagnostic Lab/Xray Outpatient	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
Emergency Room (both In and Out-of-Network)	No copay; You pay 10% AFTER Deductible
Ambulance (both In and Out-of-Network)	No copay; You pay 10% AFTER Deductible
Hospital - Inpatient (both In and Out-of-Network)	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
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