1 / 23

Medical and Prescription Drug Plan Choices

Medical and Prescription Drug Plan Choices. Medical Plan Terminology. Deductible – The dollar amount that a participant must pay for eligible health expenses before the health plan (CARES and TCU) begins to pay.

Medical and Prescription Drug Plan Choices

E N D

Presentation Transcript

1. Medical and Prescription Drug Plan Choices

2. Medical Plan Terminology • Deductible – The dollar amount that a participant must pay for eligible health expenses before the health plan (CARES and TCU) begins to pay. • Coinsurance - The portion of eligible expenses that plan members are responsible for paying after the deductible is met. It is a percentage of the total cost.

3. Medical Plan Terminology • Out-of-Pocket Coinsurance Maximum - The most coinsurance a participant will pay per year for covered health expenses before the plan pays 100% of covered health expenses for the rest of that year. The Out-of-Pocket Coinsurance Maximum does NOT include copayments or deductibles.

4. Medical Plan Terminology • Copayment (Copay) – The amount that a member must pay to the provider at the time of service.

5. Medical Plan Choices (Network benefits)

6. Copays, Deductibles and Coinsurance * All procedures (surgery, pain injections, etc.) performed at an outpatient facility are subject to copay, deductible and coinsurance.

7. Calculating Out-of-Pocket Costs - Example #1 Phil and Nancy are a married couple with one child. They don’t have chronic health issues and have estimated that they will need the following services in 2008: • 1 Preventive Care Visit per family member • 2 illness driven doctor’s office visits • 1 Preventive Mammogram for Nancy • 1 Preventive PSA for Phil • There is no deductible for preventive care services and expenses are covered at 100%. • Each plan includes a co-pay for physician office visits. Remember:

8. Calculating Out-of-Pocket CostsExample #1 * Assumes Family Coverage and Base Rx Plan

9. Calculating Out-of-Pocket Costs – Example #2 Sally is a single woman in her mid 50’s. She estimates that she will need the following services in 2008: • 1 Preventive Care Visit • 1 Preventive Mammogram • Hip Surgery • Preadmission Testing • Physical Therapy • There is no deductible for preventive care services and expenses are covered at 100%. • Each plan includes a co-pay for physician office visits. Remember:

10. Calculating Out-of-Pocket CostsExample #2 * Assumes Coverage for Employee Only and Base Rx Plan

11. Calculating Out-of-Pocket Costs – Example #3 Mary is a single mom and covers her 3 children. She estimates that her family will need the following services in 2008: • 4 Preventive Care Visits • 1 Preventive Mammogram • 4 Specialist Office Visits • 2 CT Scans • 3 Pediatrician Visits due to Illness. • There is no deductible for preventive care services and expenses are covered at 100%. • Each plan includes a co-pay for physician office visits. Remember:

12. Calculating Out-of-Pocket CostsExample #3 * Assumes Coverage for Employee and Children and Base Rx Plan

13. Prescription Plan Terminology • Formulary - A list of preferred, commonly prescribed prescription drugs. These drugs are chosen by a team of doctors and pharmacists because of their clinical superiority, safety, ease of use and cost. Also referred to as the CIGNA Healthcare Drug List.

14. Prescription Plan Terminology • Generic drug - A prescription drug that has the same active-ingredient formula as a brand-name drug. A generic drug is known only by its formula name and its formula is available to any pharmaceutical company. Generic drugs are rated by the Food and Drug Administration (FDA) to be as safe and as effective as brand-name drugs and are typically less costly.

15. Prescription Plan Terminology • Brand-name drug - A drug manufactured by a pharmaceutical company who has chosen to patent the drug's formula and register its brand name.

16. Annual Prescription Plan Contributions Contributions are rounded to the nearest dollar

17. Prescription Drug Plan Example #1Out of Pocket Cost * Assumes Employee Only Coverage

18. Prescription Drug Plan Example #2Out of Pocket Cost * Assumes Employee & Family Coverage

19. Prescription Drug Plan Example #3Out of Pocket Cost * Assumes Employee and Children Coverage

20. Flexible Spending Accounts • CIGNA will be the administrator for the 2008 plan year • Medical Spending Account Limit is \$5,000 • Dependent Spending Account Limit: • \$5,000 for single, head of household • \$5,000 for married, filing joint return • \$2,500 for each spouse if filing separate returns

21. Flexible Spending Accounts Examples of Eligible Expenses: • Deductibles, copays and coinsurance • Corrective eye surgery • Eye exams, eyeglasses, contact lenses and solution • Dental fees • Prescription drug copays and coinsurance • Orthodontia • Certain over-the-counter medicines and drugs

22. Flexible Spending Accounts Automatic Reimbursement • Pharmacy claims - \$0 payment required • Copays – you pay the provider at the time of service, CIGNA mails you a check • Deductible and coinsurance – CIGNA sends check directly to the provider or facility

More Related