10 / 50
UND ER S TAND I NG
YOUR
MEDICAL
PLAN
Medical Questions? Need to Locate a Provider?
Contact Continental Benefits (Group # CB360) at
855-347-2638 or
continentalbenefits.comor
HealthAdvocate Benefits Gateway at 866-799-2731
8
PLAN NAME
Annual Contribution
Ciner contribution - Individual
Ciner contribution - Family
Earned wellness incentive - Individual
Earned wellness incentive - Family
Benefits
In-Network
Out-of-Network
In-Network
Out-of-Network
In-Network
Out-of-Network
Coinsurance
Plan pays 80% Plan pays 60% Plan pays 90% Plan pays 60% Plan pays 80% Plan pays 60%
Individual Deductible
(per calendar year)
Family Deductible
(per calendar year)
Individual Out of Pocket Maximum
(Includes deductible and prescription expenses)
$6,000
$9,000
$5,000
$8,000
$5,000
$10,000
Family Out of Pocket Maximum
(Includes deductible and prescription expenses)
$12,000
$18,000
$10,000
$16,000
$10,000
$20,000
Preventive Office Visits
100%;
Deductible waived
100%;
Deductible waived
100%;
Deductible waived
Primary Care Office Visit
$25
Specialist Office Visit
$50
Telemedicine Visit - MDLive
$40 consult fee
Not applicable
$40 consult fee
Not applicable
$25 copay
Not applicable
Inpatient Hospital
Outpatient Surgery
Emergency Room
Ambulance
Urgent Care Visit
Lifetime Maximum
10%*
10%*
40%*
40%*
Unlimited
Unlimited
10%*
40%*
20%*
40%*
20%*
20%*
40%*
Unlimited
20%*
Not applicable
Not applicable
Not applicable
Not applicable
20%*
40%*
$6,000
$3,000
$6,000
$2,500
$5,000
Blue Plan
Green Plan
White Plan
$3,000
Annual HRA Contribution
Ciner deposit made upon enrollment
Earned incentive deposits made each payroll
$250
$750
up to $750
up to $1,000^
Annual HSA Contribution
Ciner deposit made prorata each payroll
Earned incentive deposits made each payroll
$250
$750
up to $750
up to $1,000^
Annual Contribution
Retail Prescription Drugs
(30-day supply)
$ limits are per script
Preventive
100%;
Deductible waived
100%;
Deductible waived
100%;
Deductible waived
Generic
10% to $25
$10
Preferred Brand
20% to $125
$25
Non-Preferred Brand
30% to $175
$50
Specialty
50% to $200
$200
Mail Order Prescription Drugs
(90-day supply)
$ limits are per script
Preventive
100%;
Deductible waived
100%;
Deductible waived
100%;
Deductible waived
Generic
5% to $50
$20
Preferred Brand
15% to $250
$50
Non-Preferred Brand
30% to $350
$100
Specialty
50% to $400
$400
Not Covered
Not Covered
Not Covered
10%*
^Earned wellness incentive of $1,000 = up to $750 for Employee + up to $250 for Spouse.
*Coinsurance applies after Deductible is met.
10%*
Not Covered
Not Covered
Not Covered