Medical Coverage Highlights
My Health is your central internal online resource for our health care plans. From My Health, you can easily connect to the Medical Plan claims administrators' websites to find in-network provider directories, access treatment cost estimators, check claims status, view Explanations of Benefits (EOBs), track your Medical Reimbursement Account balance, access your electronic ID card and much more. My Health also has benefits materials, tip sheets and other information on health and wellness.
Option 1 and Option 2 of the Medical Plan, each offered through Aetna and Cigna, are "Consumer Driven Health Plan" options. Both options cover the same medically necessary services and supplies, including prescription drugs and pre-existing conditions.
However, Option 1 has higher payroll contributions but generally lower annual deductibles and annual coinsurance maximums, while Option 2 has lower payroll contributions but generally higher annual deductibles and annual coinsurance maximums.
Option 1 and Option 2 benefits are offered through a network of participating health care providers (for example, doctors, hospitals, labs, and outpatient facilities that belong to Aetna and Cigna's networks). You can visit any provider each time you need care, even if it's not in the network. However, the most cost-effective care will always be available through in-network providers who have agreed to accept pre-negotiated rates.
- Eligible in-network preventive care (including physical exams and recommended preventive screenings) and eligible preventive generic drugs are covered at 100% with no deductible, coinsurance, or copayments.
- Important: In-network primary care office visits are covered at 90% with no deductible. Primary care physicians include doctors who practice family medicine, internal medicine (and are contracted with Aetna or Cigna as Primary Care Physicians), obstetricians/gynecologists, and pediatricians. Visits to convenience care clinics, such as CVS Minute Clinic®, are also considered primary care visits.
- Virtual doctor visits provide on-demand 24/7/365 access to non-urgent primary care services at 90% with no deductible through a national network of licensed, board-certified, U.S.-based doctors, including pediatricians. Virtual doctor visits with mental health providers are covered at 80% after the deductible.
- When you receive non-primary care medical services, you'll need to satisfy an annual deductible — a set amount that you pay out-of-pocket — before the Plan shares in the cost for care. There are separate deductibles for in- and out-of-network care and for prescription drugs.
- After you satisfy the deductible, the Plan pays a percentage (generally 80% in-network and 50% out-of-network) of the cost. Your share — called coinsurance, the amount you and the Plan pay for certain expenses — after the deductible is typically 20% of the cost of in-network care and 50% of the cost for out-of-network care. The amount of coinsurance you have to pay each year is limited by separate annual in-network and out-of-network coinsurance maximums, which act as a financial "safety net." In-network charges do not apply toward the out-of-network deductible or coinsurance maximum — and vice versa. Benefits for out-of-network care are limited to reasonable and customary (R&C) charges. These charges are based on average claims data in your area and are determined by your health care company to be appropriate fees. Out-of-network charges are typically higher than the pre-negotiated rates for in-network care. You are responsible for paying any amount above R&C charges.
- If you see an in-network provider, you will generally not have to pay anything at the point of service, and you will not have to file a claim. Your provider will typically submit your claim electronically to your health care company using the information on your ID card.
- Prescription drug benefits are part of your coverage. The Prescription Drug Plan has a different plan design than other Medical Plan features and is subject to a separate deductible and a separate safety net in the form of per-prescription maximums and an annual out-of-pocket maximum.
Contribution rates vary by the types of dependent whom you choose to cover — for example, a spouse/domestic partner vs. a child. You will be charged for up to a maximum of four children, regardless of how many additional children you choose to cover. (You can cover all of your children, as long as they meet eligibility requirements.) Contributions will also vary based on your Total Annual Cash Compensation, geographical location, the Medical Plan option you select, you and your covered spouse's/domestic partner's tobacco user status, and you and your covered spouse's/domestic partner's Initial Wellness completion status. The amount you pay does not differ depending on whether you choose Aetna or Cigna as your health care company.