BL Companies | 2022 Benefits Brochure

CIGNA MEDICAL & PHARMACY COVERAGE

MEDICAL BENEFITS

OPTION 1 — STANDARD PPO In-Network

OPTION 2 — LOWER COST PPO OPTION 3 — HDHP WITH HSA In-Network Out-of-Network In-Network Out-of-Network $750** $20,000 $2,000 $20,000 $2,250** $60,000 $4,000 $60,000

Out-of-Network

Individual Deductible Family Deductible

N/A N/A

$20,000 $60,000

OUT-OF-POCKET MAXIMUM Individual

$1,500 $4,500

$50,000 $150,000

$2,000 $6,000

$50,000 $150,000

$3,000 $6,000

$50,000 $150,000

Family

Coinsurance

N/A

50% 50%

N/A

50% 50%

10%

50% 50%

Preventative Care Services No Charge AMOUNT YOU PAY AFTER DEDUCTIBLE (on copay plans there is no in-network deductible) Primary Physician Office Visits $20 Copay

No Charge

No Charge

$25

50%

10%

50%

50%

$50

50%

10% 10% 10% 10%

50%

Specialist Office Visits Emergency Room Visits

$40 Copay $200 Copay $40 Copay

50%

$300

$75

50% 50%

Urgent Care

0% After Deductible 0% After Deductible

50%

Inpatient Hospital Services* Outpatient Facility Services*

$100 Copay per day/Max $500

50%

50%

10%

50%

$100 Copay

50%

RETAIL PRESCRIPTION DRUGS Generic

$15 $45 $90 $15 $45 $90

Not Covered 10% Not Covered 10% Not Covered 10% Not Covered 10% Not Covered 10% Not Covered 10%

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

$10 $30 $70

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

Preferred Brand

Non-Preferred Brand

MAIL-ORDER PRESCRIPTION DRUGS Generic $10

Preferred Brand

$30 $70

Non-Preferred Brand

OPTION 1 —

BL Companies will provide HSA funding for the HDHP plan: $750 for individuals, $1,500 for plans with 1 or more dependents

**Inpatient hospital and outpatient surgery only. Inpatient hospitalization includes semi-private room & board, maternity, skilled nursing facility, hospice, mental health, substance abuse, and short term rehabilitation.

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