Cigna Open Access Plus - Nationwide Monthly Premiums

Transcription

1 Cigna Open Access Plus - Nationwide Subscriber Subscriber only $2, (Cigna Medicare Surround) with dependent $2, $4, $4, For a directory of providers, contact Cigna Customer Service or use ProviderSearch on the Cigna web site at $6, A -

2 Cigna HMO - California Only Subscriber Subscriber only $1, with Medicare (SCAN Health Plan) with dependent $1, $3, $3, $4, Assignment of Primary Care Physician within the Cigna HMO - B -

3 Sharp Direct Advantage HMO - San Diego County Only This plan is sponsored by SDPEBA, and available to all retirees. All questions regarding this plan should be directed to SDPEBA Benefits: Phone: or info@sdpeba.org Subscriber With Medicare Subscriber only $ $ Choice of physician and hospital Choice of Primary Care Physician within the Sharp Advantage with dependent. $1, $1, $2, Kaiser HMO - California Only Subscriber Without Medicare Subscriber only $1, $1, Choice of Primary Care Provider within the Kaiser Permanente of California. with dependent. $2, $2, $3, Out of state Kaiser available in GA, HI, WA, OR and CO. Contact SDCERS for information. - C -

4 Kaiser Senior Advantage HMO - California Only Subscriber Subscriber only $ $ $1, Choice of Primary Care Provider within the Kaiser Permanente of California with dependent $1, $2, Sharp Health Plan HMO - San Diego County Only Subscriber Without Medicare Subscriber only $1, with dependent. $1, $2, $2, This plan is sponsored by SDPEBA, and available to all retirees. All questions regarding this plan should be directed to SDPEBA Benefits: Phone: or info@sdpeba.org $3, D -

5 Concordia Plus DHMO Dental - California Only Coverage effective August 1, 2018 through July 31, 2019 Coverage For Monthly Premium Subscriber Only $10.95 Subscriber + One $22.01 Subscriber + Family $43.89 Group Number Customer Service Website To find a dentist, select the DHMO Concordia Plus provider network Concordia Flex PPO Dental - Nationwide Coverage effective August 1, 2018 through July 31, 2019 Coverage For Monthly Premium Subscriber Only $19.66 Subscriber + One $39.33 Subscriber + Family $68.17 Covered Services Group Number Customer Service Website To find a dentist, select the Alliance provider network Dentist Non- Dentist Covered Services Class I Diagnostic/Preventive Services Class II Basic Services Class III Major Services Orthodontics Adult and Dependent Treatments Cosmetics Services and Implants Implant Prosthetics/Surgery, Veneers & Bleaching Annual Program (per person) Lifetime Orthodontic (per person) Dentist Plan pays 100% $0-$140 co-pay 1 $0-$255 co-pay 1 $1,500-$2,000 co-pay 1 No maximum 1 No maximum 1 Non- Dentist 1 Please refer to the Concordia Plus co-payment schedule at for additional details on services and member co-payments. - E - Class I Diagnostic/Preventive Services Class II Basic Services Class III Major Services Orthodontics Adult and Dependent Treatments Cosmetics Services and Implants Implant Prosthetics/Surgery, Veneers & Bleaching Annual program maximum (per person) Lifetime Orthodontic (per person) Annual Program Deductible (per person/per family) Plan pays 100% Plan pays 70% Member pays Allowable Charge Member pays Allowable Charge Member pays Allowable Charge Plan pays 100% of Allowable Charge Plan pays 70% of Allowable Charge $1,000 Class I & II (unlimited for Class III) None $50/$150 Class II only 1Discounted services are not insurance. Discounts vary by dentist, service & geographic area. Allowable Charge available by calling United Concordia Customer Service with the procedure code or dentist can submit a predetermination to United Concordia.

6 VSP Choice Vision Plan - Nationwide Coverage For Subscriber Only $6.38 Subscriber + One $12.75 Subscriber + Two or more $14.97 Monthly Premium Customer Service Group Number Website Covered Services Description Copay Frequency WellVision Exam Focuses on your eyes and overall wellness $0 Every 12 months Prescription Glasses $0 See frame and lenses Frame $105 allowance for a wide selection of frames $125 allowance for featured frame brands 20% savings on the amount over your allowance $60 Costco frame allowance Every 24 months Lenses Single vision, lined bifocal, and lined trifocal lenses Polycarbonate lenses for dependent children Every 12 months Lens Enhancement Scratch-resistant coating Polycarbonate lenses Photochromic lenses Standard progressive lenses Premium progressive lenses Custom progressive lenses Average savings of 20-25% on other lens enhancements $17 $31-$35 $70 $55 $95-$105 $150-$175 Every 12 months Contacts Diabetic Eyecare Plus Program $100 allowance for contacts 15% off contact lens exam (fitting and evaluation) Services related to diabetic eye disease, glaucoma and age-related macular degeneration (AMD). Retinal screening for eligible members with diabetes. Limitations and coordination with medical coverage may apply. Ask your VSP doctor for details. Other Dental and Vision Plans Up to $60 Every 12 months $20 As needed There are several plans available to City retirees through outside organizations. IMPORTANT: SDCERS does not administer these plans and is unable to answer questions or provide materials related to these plans. Please contact the number listed for each plan for more information. Offered through Type of Plan(s) Contact information Retired Fire & Police Association (offered to members or surviving spouses of members of the RFPA) San Diego Public Employee Benefit Association (SDPEBA) (offered to all retirees) Local 127 (offered to Local 127 Retirees) Dental, Vision, etc. Dental: Metlife PPO & HMO Vision: VSP Vision Dental: Dental Health Services PPO & HMO - F - Contact: Pacific Group Agencies, Inc SDPEBA Benefits Goldman & Walker Insurance

7 SCAN Health Plan - California Only Subscriber Subscriber only $ without Medicare (Cigna HMO) $ $1, within the Scripps network Assignment of Primary Care Physician within the SCAN Health Plan. and one additional dependent $1, $3, G -

8 Cigna HMO COB - California Only Subscriber Subscriber only $ (Cigna HMO) with dependent $ $1, $2, Can use physicians and hospitals within Cigna s HMO network, or any physician or hospital who accepts Medicare. If you use providers outside of the network, you will be responsible for any amount that Medicare does not pay. $3, Cigna Medicare Surround - Nationwide Subscriber Subscriber only $ without Medicare (Cigna Open Access Plus) $ $2, Any physician or hospital that accepts Medicare. Choosing a provider that accepts Medicare assignment will ensure the lowest out-of-pocket expenses. To find a Medicare provider call MEDICARE or visit and one additional dependent $2, $4, H -