[PDF] Summary of Benefits and Coverage Completed Example





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Summary of Benefits and Coverage Completed Example

30 nov. 2021 name social security number



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ORDINANCE NO. 613 AN ORDINANCE OF THE CITY OF

1 janv. 2017 TO AMEND BRISBANE MUNICIPAL CODE TITLE 15 BUILDINGS AND CONSTRUCTION

IBEW AECA

FAMILY HEALTH

IBEW LOCAL 613 & CONTRIBUTING EMPLOYERS

FAMILY HEALTH PLAN

ALL PARTICIPANTS MUST COMPLETE THE ENROLLMENT BY NOV 30th /d[^d/DdKEZK>>J DURING ANNUAL ENROLLMENT EACH YEAR, IT IS IMPORTANT THAT YOU:

UPDATE

CHOOSE

ENROLL

YOU MUST COMPLETE ENROLLMENT IN ORDER FOR

YOUR DEPENDENTS TO HAVE COVERAGE IN 2022

2022 OPEN ENROLLMENT

Page 2

ALL PARTICIPANTS MUST COMPLETE THE ENROLLMENT BY NOV 30th THIS YEAR WE ARE USING AN ONLINE ENROLLMENT APPLICATION THAT CAN BE ACCESSED RIGHT INSIDE YOUR MEMBER PORTAL t JUST A SINGLE SIGN ON TO ENROLL AND VIEW INFORMATION ON YOUR BENEFITS, WORK HISTORY AND MORE!

ENROLLMENT IS FAST AND EASY t

oe oe oe oe oe oe oe oe oeʹ If you fail to complete enrollment, you will be defaulted to Employee Only coverage for 2022 t this means your dependents will not be eligible for benefits effective January 1, 2022 unless you complete your enrollment and you select to cover them.

2022 OPEN ENROLLMENT

Page 3

ALL PARTICIPANTS MUST COMPLETE THE ENROLLMENT BY NOV 30th

SUMMARIES OF BENEFITS AND COVERAGE (SBCs):

REMEMBER:

x x x x

To request a special enrollment period or to obtain more information about your special enrollment rights,

contact the Fund Office at 1-800-922-1613. CURRENT DENTAL BENEFITS WILL STILL BE PROVIDED THROUGH CIGNA FOR BOTH COVERAGE OPTIONS

The above comparison just highlights basic benefits and is not intended to fully describe all benefit coverages.

HIGHLIGHT COMPARISON OF 2022 FAMILY HEALTH PLAN COVERAGE OPTIONS COVERAGE UNDER BOTH OPTIONS IS FOR IN-NETWORK PROVIDERS ONLY (plus Non-Network Emergency Services)

CIGNA OAP KAISER HMO

NETWORK UTILIZED CIGNA OPEN ACCESS PLUS KAISER PERMANENTE HMO IF YOU NEED TO SEE THE DOCTOR Calendar Year Deductible does not apply

Primary Care You pay $35 You pay $20

Specialist You pay $45 You pay $35

Mental Health You pay $35 You pay $20

Virtual Visit/Telemedicine You pay $35 You pay $0

WHEN YOU RECEIVE PREVENTIVE CARE Calendar Year Deductible does not apply ACA Preventive Care Services You pay $0 You pay $0

IF YOU NEED A PRESCRIPTION DRUGS

ACA PREVENTIVE CARE DRUGS

PRESCRIPTION DEDUCTIBLE

You pay $0, no deductible

$25 per individual per calendar year

You pay $0, no deductible

None RETAIL (30-day supply) After deductible: If filled at Kaiser Facility:

Tier 1: Generic You pay $10 You pay $10

Tier 2: Preferred Brand You pay greater of $25 or 25% You pay $25 Tier 3: Non-Preferred Brand You pay greater of $25 or 25% Not covered

HOME DELIVERY (90-day supply)

Tier 1: Generic You pay $30 You pay $20

Tier 2: Preferred Brand You pay greater of $75 or 25% You pay $50 Tier 3: Non-Preferred Brand You pay greater of $75 or 25% Not covered

SPECIALTY (30-day supply)

Specialty Medications You pay greater of $25 or 25% You pay $25

IF YOU NEED OTHER MEDICAL SERVICES

CALENDAR YEAR DEDUCTIBLE (CYD)

Individual $750 $250

Family $2,500 $750

MAXIMUM OUT-OF-POCKET

Individual $6,350 $6,350

Family $12,700 $12,700

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