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2015 — 2016 Plan Design <br />Attachment number 1 <br />F -6 Page 77 <br />2014 - 2015 Renewal <br />2015 - 2016 Renewal <br />Current <br />Renewal <br />CIGNA <br />Self- funded OAP <br />CIGNA <br />Self- funded HSA <br />CIGNA <br />Self- funded OAP <br />CIGNA <br />Self- funded HSA <br />In- Network <br />In- Network <br />In- Network <br />In- Network <br />OAP <br />Health Savings <br />Account <br />OAP <br />Health Savings <br />Account <br />County Contribution to an HSA Account <br />None <br />$750 <br />None <br />$750 <br />Coinsurance Limit <br />Single $3,000 <br />Family $6,000 <br />Single $2,000 <br />Family $2,000 <br />Single $3,150 <br />Family $6,300 <br />Single $2,000 <br />Family $2,000 <br />Lifetime Maximum <br />None <br />None <br />None <br />None <br />Deductible - Individual <br />$1,000 <br />$1,500 <br />$1,000 <br />$1,500 <br />Deductible - Family <br />$3,000 <br />$3,000 <br />$3,000 <br />$3,000 <br />Office Visits to Your PCP <br />$30 Copay <br />Ded /Coinsurance <br />$30 Copay <br />Ded /Coinsurance <br />Uiiice visit to a specialist <br />ueu /Co IF] surance <br />IJUU /k-uirisUFdII e <br />ueu /Coinsurance <br />ueu/k_uirisUFdII e <br />Wellness Benefits <br />100% <br />100% <br />100% <br />100% <br />Inpatient Hospital Care <br />Ded /Coinsurance <br />Ded /Coinsurance <br />Ded /Coinsurance <br />Ded /Coinsurance <br />Outpatient Surgery <br />Ded /Coinsurance <br />Ded /Coinsurance <br />Ded /Coinsurance <br />Ded /Coinsurance <br />Emergency Room Visit <br />Ded /Coinsurance <br />Ded /Coinsurance <br />Ded /Coinsurance <br />Ded /Coinsurance <br />Urgent Care <br />Ded /Coinsurance <br />Ded /Coinsurance <br />Ded /Coinsurance <br />Ded /Coinsurance <br />Prescription Drugs <br />$150 Deductible <br />Brand Only <br />$5/$45/$60 - 2x Mail <br />Ded /Coinsurance <br />$5/$45/$60 - 2x Mail <br />Ded /Coinsurance <br />Benefit Percentage <br />80% <br />80% <br />80% <br />80% <br />Health <br />Reimbursement <br />Account - $225 <br />Health <br />Reimbursement <br />Account - $225 <br />Attachment number 1 <br />F -6 Page 77 <br />