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12
2017 Stantec
Benefits Guide
Benefit Highlights
In-Network
Out-of-Network
Routine office visits
Plan pays 80% (after deductible)
Plan pays 60% of the allowed amount
(after deductible)
Specialist visits
Plan pays 80% (after deductible)
Plan pays 60% of the allowed amount
(after deductible)
Preventive care
Plan pays 100%
according to the National Medical
Specialty Recommended Schedule
(deductible waived)
Plan pays 60% of the allowed amount
according to the National Medical
Specialty Recommended Schedule
(after deductible)
Urgent care (physician
and medical services)
Plan pays 80% (after deductible)
Plan pays 60% of the allowed amount
(after deductible)
Emergency room
Plan pays 80% (after deductible)
Plan pays 80% (after deductible)
Hospital inpatient
and outpatient
Plan pays 80% (after deductible)
Plan pays 60% of the allowed amount
(after deductible)
Mental health
Inpatient: Plan pays 80% (after
deductible)
Outpatient: Plan pays 80% (after
deductible)
Plan pays 60% of the allowed amount
(after deductible)
Substance abuse
Inpatient: Plan pays 80% (after
deductible)
Outpatient: Plan pays 80% (after
deductible)
Plan pays 60% of the allowed amount
(after deductible)
Outpatient scans
and lab
Lab and non-complex imaging (x-ray):
covered at 100%
(deductible
waived for HRA ONLY
)
(deductible
applies for HSA plans if not
preventive
)
Plan pays 60% of the allowed amount
(after deductible)
Complex imaging (MRI, CT, CAT, PET):
Plan pays 80% (after deductible for
HRA and HSA plans
)
Plan pays 60% of the allowed amount
(after deductible)
Chiropractic care
Plan pays 80% (after deductible)
Maximum of 20 visits per year
Plan pays 60% of the allowed amount
(after deductible)
Residents of Alaska:
“out-of-network” benefits are enhanced in your area due to limited access to in-
network providers. Please reference your Cigna summaries for more details.
Important Information about Deductibles and Out-of-Pocket Maximums
Your deductible applies for the full plan year: January 1 to December 31. Expenses from the
current plan year are not carried over to the following plan year. Under the Health Reimbursement
Arrangement (HRA) and HSA Buy-Up plans, there is only one deductible and one out-of-pocket
maximum for families, and each can be satisfied by one or any combination of family members
covered under the plan. No individual deductible applies to members of a family on these two
plans. However, because of IRS regulations, an individual deductible and individual out-of-pocket
maximum apply to family members under the HSA Base and the HSA Value plans.