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4
Medical Coverage
Year after year, SLFHC remains committed to providing its employees and their families with quality healthcare at an affordable cost.
Effective January 1, 2017, employees will continue to have an opportunity to enroll in the Consumer Driven High Deductible Plan
(CDHDP)
in conjunction with a Health Savings Account
(HSA)
.
By enrolling in the CDHDP option, you will be given the flexibility of a medical plan together with an employer funded Health Savings
Account (HSA). SLFHC will contribute benefit dollars on your behalf to your HSA which you can use to cover 100% of medical and
pharmacy expenses until the fund is used up.
1
This amount represents the Company contribution only; however, employees can also contribute to a combined maximum of $3,400 one person/$6,750 fam-
ily. If age 55 or over, you can contribute $1,000 in catch-up contributions. Funds remaining in your HSA at the end of the year will rollover to next year.
2
Embedded deductible means that if the individual deductible is reached by one member of the family, that individual is covered in network at 100% even if the
family has not met its aggregate deductible.
Cigna HSA CDHDP
Plan Provisions
In-Network
Out-of-Network
Company Contribution to HSA
1
(Individual/Family)
$1,500 / $3,000
Annual Deductible
2
(Individual/Family) Embedded
$3,500 / $6,500
$6,000 / $12,000
Out-of-Pocket Maximum
(Includes Deductible & Copays)
$6,500 / $13,000
$12,000 / $24,000
Lifetime Maximum
Unlimited
Preventive Care
100%
Not covered
Primary Physician Office Visit
100% after deductible
50% after deductible
Specialist Office Visit
100% after deductible
50% after deductible
X-Ray and Lab
100% after deductible
50% after deductible
Advanced Imaging
(PET, MRI, CAT, MRA)
100% after deductible
50% after deductible
Inpatient Hospital Services
100% after deductible
50% after deductible
Outpatient Hospital Services
100% after deductible
50% after deductible
Urgent Care
100% after deductible
Emergency Room Care
100% after deductible
Prescription Drug Deductible
(Individual/Family)
Medical plan deductible applies.
Waived for preventative drugs
Retail Prescription Drugs
(30 day)
• Generic
• Brand Preferred
• Brand Non-preferred
$15 copay
$25 copay
$40 copay
70% after deductible
Mail Order Prescription Drugs
(90 day)
• Generic
• Brand Preferred
• Brand Non-preferred
$30 copay
$50 copay
$80 copay
N/A
Cigna HSA CDHDP with Local Plus Network
In-Network
Out-of-Network
$1,500 / $3,000
$3,500 / $6,500
$6,000 / $12,000
$6,500 / $13,000
$12,000 / $24,000
Unlimited
100%
Not covered
100% after deductible
50% after deductible
100% after deductible
50% after deductible
100% after deductible
50% after deductible
100% after deductible
50% after deductible
100% after deductible
50% after deductible
100% after deductible
50% after deductible
100% after deductible
100% after deductible
Medical plan deductible applies.
Waived for preventative drugs
$15 copay
$25 copay
$40 copay
70% after deductible
$30 copay
$50 copay
$80 copay
N/A