health plan options insurance education part #2. health plan options choices state health plan ...
TRANSCRIPT
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Health Plan Options
Insurance Education Part #2
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Health Plan Options
Choices• State Health Plan
Standard Plan Savings Plan
• HMOs BlueChoice HealthPlan*
(available statewide) CIGNA HMO*
*Must live or work in service area
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Health Plan OptionsStandard Plan
and Savings Plan
(Features the Plans have in Common)
Insurance Education Part #2
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State Health Plan (SHP)Standard Plan and Savings Plan
• Network providers
• Out-of-network benefits
• BlueCard Program
• Preventive benefits
• Rx network providers
• Mental health and substance abuse benefits
• Medi-Call/APS pre-authorization requirements
Standard Plan and Savings Plan(common to both)
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Provider Network and
BlueCard Advantage• Freedom of choice• Worldwide coverage• Easy access to medically necessary care
• Providers file claims• Subscriber pays deductible and coinsurance
SHP Standard Plan and Savings Plan
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(cont.)
• Subscribers not balance-billed for charges over allowed amount (negotiated pricing)
• SHP ID card (Preferred Provider Organization, or PPO, logo located in bottom corner of ID card)
• National PPO organization coverage
• Worldwide coverage• Call 800-810-BLUE
SHP Standard Plan and Savings Plan
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Non-network Benefits• Freedom of choice (will receive higher level of benefits when using network providers)
• Worldwide coverage• Easy access to medically-necessary care
SHP Standard Plan and Savings Plan
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SHP Standard Plan and Savings Plan
(cont.)
• Subscriber may have to file claims
• Subscriber pays deductible and higher coinsurance maximum
• Subscriber can be balance-billed (provider can charge more than allowed amount no negotiated pricing for non-network services)
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SHP Standard Plan and Savings Plan
Preventive Benefits (must follow Plan guidelines)• Mammography testing• Pap Test• Well-child care• Routine colonoscopy• Worksite health screening (available to HMO subscribers as well)
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Mammography Testing• 100 percent coverage for routine, four-view mammograms, according to Plan guidelines
• Performed at participating mammography facilities
SHP Standard Plan and Savings Plan
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(cont.)
• Ages 35-39 (one routine mammogram during those years)
• Ages 40-74 (one routine mammogram every 12 months)
• Deductible and coinsurance apply to diagnostic mammograms
SHP Standard Plan and Savings Plan
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Pap Test• No deductible or coinsurance• Subscriber free to choose provider• One Pap Test each year for covered females, ages 18 through 65
• For routine and diagnostic Pap Tests
• Pays lab costs only - routine office visit NOT covered
SHP Standard Plan and Savings Plan
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Well-child Care Benefits• Well-child checkups
Five visits for children younger than 1 year old
Three visits for children 1 year and older
One visit per year for children age 2 through 18
SHP Standard Plan and Savings Plan
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(cont.)
• 100 percent benefit for regular check-ups provided by network providers
• 100 percent benefit for covered immunizations, according to recommended schedule (catch-up provision for delayed or missed immunizations through age 18)
SHP Standard Plan and Savings Plan
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(cont.)
• Covered immunizations Diphtheria-Tetanus-Pertussis (DTP)
Polio Hepatitis A and B Haemophilus (Hib)
SHP Standard Plan and Savings Plan
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SHP Standard Plan and Savings Plan
(cont.)
• Additional covered immunizations Measles-Mumps-Rubella Chicken pox Pneumoccocal vaccine (Prevnar) HPV (Human Papilomavirus) Influenza Meningococcal
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Routine Colonoscopies• One routine colonoscopy every 10 years for subscribers age 50 and older
• Subject to deductible and coinsurance
• Diagnostic colonoscopy subject to deductible and coinsurance
SHP Standard Plan and Savings Plan
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Prevention Partners
(State Employee Wellness Program)
• Worksite screening available to employees and spouses covered by State Health Plan or HMO/POS Subscriber/spouse pays $15 for screening
SHP Standard Plan and Savings Plan
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One screening a year, per eligible SHP subscriber and covered spouse• $15 per eligible subscriber• For active and retired subscribers
and their spouses • Whose primary coverage is one of
state’s health plans and• Is not eligible for Medicare
(cont.)
SHP Standard Plan and Savings Plan
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• Chemistry profile (BUN, Glucose)
• Hemogram (Hemoglobin)
• Health risk appraisal
• Blood pressure check
• Height and weight measurement
• Lipid profile (cholesterol)
• Confidential personal report
• Confidential, personal consultation about results upon request
Screening Benefits
SHP Standard Plan and Savings Plan
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Retail Rx Maintenance Network• Visit www.eip.sc.gov• Choose your category• Go to online directories• Select “State Health Plan Retail Maintenance Network”
• Plan administrator -- Medco • Medco Customer Service: 800-711-3450
SHP Standard Plan and Savings Plan
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My Rx Choices May help SHP subscribers pay less for long-term prescriptions
Locate lowest-cost prescriptions using Medco’s online cost comparison tool
Access “My Rx Choices” online to compare drug costs by visiting:
www.Medco.com
See Insurance Benefits Guide for details
SHP Standard Plan and Savings Plan
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Medi-Call (state managed care)• State Health Plan’s utilization review program for medical/ surgical benefits
• Ensures subscriber and covered family members receive appropriate medical care in most beneficial, cost-effective manner
SHP Standard Plan and Savings Plan
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SHP Standard Plan and Savings Plan
(cont.)
• Some services requiring a Medi-Call Provider may call for subscriber; however, subscriber has responsibility for calling Medi-Call for pre-authorization
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SHP Standard Plan and Savings Plan
(cont.)
• Some services include All inpatient admissions Emergency admissions within 48 hours or next business day
All outpatient surgery in hospital or ambulatory surgical center
Hospice services Home health care services
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(cont.) Skilled nursing service In-vitro fertilization procedures Call during first trimester of pregnancy
MRI, MRA, CT or PET scan
• Consult Insurance Benefits Guide for complete listing of services requiring a Medi-Call
SHP Standard Plan and Savings Plan
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SHP Standard Plan and Savings Plan
(cont.)
• Penalties if Medi-Call not contacted $200 penalty (penalty does not apply to coinsurance maximum)
Charges for services not pre-authorized by Medi-Call do not apply toward deductible or coinsurance maximum
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Medi-CallColumbia:
803-699-3337SC, nationwide and Canada:
800-925-9724
SHP Standard Plan and Savings Plan
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Mental Health/Substance Abuse
• Administered by APS• Coverage for medically necessary treatment of mental health and substance abuse conditions
• Same coinsurance, deductible and out-of-pocket amounts as for physical conditions
SHP Standard Plan and Savings Plan
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• Must use participating provider or no benefits paid
• Can nominate provider for network
(cont.)
SHP Standard Plan and Savings Plan
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• Inpatient/outpatient care Pre-authorization required before receiving care
Call APS: 800-221-8699• Outpatient treatment beyond 10 visits must be reviewed for medical necessity
(cont.)
SHP Standard Plan and Savings Plan
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Tobacco Cessation Benefits• Free & Clear Program, administered by APS
• Free for subscribers and covered dependents
SHP Standard Plan and Savings Plan
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SHP Standard Plan and Savings Plan
Contact Free & Clear to participate at:866-QUIT-4-LIFE(866-784-8454)
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SHP Standard Plan
Insurance Education Part #2
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Coinsurance Out-of-network• Plan pays 60%
• Subscriber pays 40%
Coinsurance Maximum• $4,000 individual
• $8,000 family
Annual Deductible• $350 individual• $700 family
Coinsurance In-network• Plan pays 80%
• Subscriber pays 20%
Coinsurance Maximum• $2,000 individual
• $4,000 family
Deductibles and Coinsurance
Standard Plan
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Per-occurrence Deductibles• $125 emergency room visit (waived if admitted)
• $75 out-patient hospital service (some exceptions apply)
• $10 per office visit• Do not apply toward annual deductibles or coinsurance maximums
Standard Plan
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• Must use participating network pharmacy
• Most major pharmacies nationwide and many independent pharmacies in SC
• Show State Health Plan ID card• List of participating pharmacies on EIP Web site
Prescription Drug Program Pharmacy Network
Standard Plan
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Participating Retail Pharmacy(up to 31-day supply)
• $10 tier one • $25 tier two• $40 tier three
Mail-Order Pharmacy(up to 90-day supply)
• $25 tier one • $62 tier two• $100 tier three
Prescription Drug Program
Standard Plan
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Prescription Drug Program Facts
• Annual copayment maximum of $2,500 per person
• Coordination of benefits
Standard Plan
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• “Pay the Difference” If generic brand drug is available and subscriber or doctor chooses brand name, subscriber responsible for difference in price between the allowable charge for name brand and generic brand, plus generic brand copayment
(cont.)
Standard Plan
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“Pay the difference” does not apply to $2,500 out-of-pocket maximum
Generic copayment does apply to out-of-pocket maximum
(cont.)
Standard Plan
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Savings Plan Health Savings Accounts
(HSA)and
Limited-use Medical Spending Accounts
Insurance Education Part #2
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Choice for Subscribers Who: Want lower premiums Are willing to take more responsibility for their healthcare
Want to save for major medical expenses through Health Savings Account
Savings Plan
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Annual Deductible• $3,000 individual• $6,000 family (no embedded deductible)
Savings Plan
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Rules• Subscriber pays 100 percent of allowable charges for medical costs In-network provider: SHP allowance applies toward deductible
Out-of-network provider: SHP allows only what Plan would have allowed if subscriber used in-network provider
Savings Plan
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• No per-occurrence deductibles
• Reimbursement for annual flu shot
• Annual physical to include specific services
• Eligible to contribute to Health Savings Account (HSA)
(cont.)
Savings Plan
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(cont.)
• Subscriber pays 100 percent of allowable charges for prescription costs Must use in-network pharmacies only to pay negotiated rate
Negotiated rate not available when using out-of-network pharmacies
Savings Plan
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In-network Coinsurance• Plan pays
80%• Subscriber pays
20%• Coinsurance Maximum
$2,000 individual $4,000 familyOut-of-network Coinsurance
• Plan pays60%
• Subscriber pays40%
• Coinsurance Maximum $4,000 individual $8,000 family
Coinsurance
Savings Plan
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Restrictions and Exclusions • Chiropractic payments
Limited to $500 per person (after deductible)
• Rx drug benefits exclude Drugs for erectile dysfunction Non-sedating antihistamines
Savings Plan
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Health Savings Account Facts• Tax-sheltered investment accounts used to pay qualified medical expenses
• Money rolls over from year-to-year Cannot be covered by another health plan, including Medicare or Medical Spending Account
Health Savings Accounts (HSA)
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Contributions to HSA allowed only when participating in high-deductible health plan (i.e. SHP Savings Plan)
Spouse and dependents do not need to be covered by SHP Savings Plan to be eligible to receive claims reimbursement for covered services
(cont.)
Health Savings Accounts
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• Contributions payroll deducted and tax-free
• If contributions direct-deposited, can deduct on tax return
• Keep receipts in event of an IRS audit Tax-free for qualified medical expenses
(cont.)
Health Savings Accounts
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• If HSA funds used for non-qualified medical expenses, Amount is included in income and IRS penalty applies unless subscriber
• Becomes disabled• Enrolls in Medicare• Dies
(cont.)
Health Savings Accounts
• More HSA information on IRS Web site: www.irs.gov
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(cont.)
• HSA account does NOT advance money
• Annual HSA contributions for 2008 limited to: $2,900 for individual $5,800 for family
• Catch-up provision for individuals age 55 and older allows additional $900 for 2008
Health Savings Accounts
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Health Savings Accounts
(cont.)
• $1/mo (payroll deducted) administrative fee (FBMC) HSA funds earn interest and are tax free
HSA portable when employment ends
Subscriber must complete “authorization packet” received from NBSC to activate account
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• How to access funds from HSA Free VISA® debit card from NBSC Checks provided - $.35 fee per check
written $1/month or $10/yearly administrative
fee until balance reaches $2,500 (NBSC)
(cont.)
Health Savings Accounts
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“Limited Use” MSA Facts Can use for vision and dental expenses only (maximum $5,000) $3.50 per month administrative
fee applies Must be continuously employed
for one year to enroll
“Limited Use” Medical Spending Accounts (MSA)
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(cont.)
• “Use it or lose it” (funds do not roll over as with HSA)
• Claims must be incurred by March 15th grace period and submitted by March 31st
• Not eligible for EZ REIMBURSE® Card
“Limited Use” Medical Spending Accounts (MSA)
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My InsuranceManager
BCBS of South Carolinawww.southcarolinablues.com
Insurance Education Part #2
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My Insurance Manager’s Features • Review claims via BCBS Web site• View and print Explanation of Benefits (EOB)
• See amount paid toward deductible and coinsurance maximum
• Secure E-mail customer service questions
• View up-to-date provider directory • Request new ID card
My Insurance ManagerBCBS of South Carolina
(www.southcarolinablues.com)
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Health Insurance Options
Health Maintenance Organizations
(HMOs)
Insurance Education Part #2
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Rules• Subscribers must choose primary care physician (PCP)
• Referral required for most specialty care
• You must live or work in HMO service area
Health Maintenance Organizations (HMOs)
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(cont.)
• Provide qualified emergency service out-of-network
• No non-emergency out-of-network benefits
• Read HMO materials carefully before making health plan selection
Health Maintenance Organizations (HMOs)
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BlueChoice HealthPlan
Insurance Education Part #2
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Features• Annual deductible
Amount subscriber pays before HMO begins paying (deductible does not apply to PCP charges)
$250 individual $500 family
BlueChoice HealthPlan(available in all South Carolina counties)
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• After subscriber pays annual deductible and copayment, plan pays 90 percent of allowable charges subscriber pays 10 percent, which applies to coinsurance maximum
(cont.)
BlueChoice HealthPlan(available in all South Carolina counties)
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• Hospital copayments $100 outpatient hospital copay $125 emergency copay $200 inpatient hospital copay
(cont.)
BlueChoice HealthPlan(available in all South Carolina counties)
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Physical therapy, speech therapy and occupational therapy Covered after annual deductible met Plan pays 90 percent of allowable
charges; subscriber pays 10 percent Limit per plan year: 20 visits per type of
“therapy”
(cont.)
BlueChoice HealthPlan(available in all South Carolina counties)
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• Coinsurance maximum Most an individual or family will pay for
covered services Excludes deductibles and copays $1,500 individual $3,000 family
(cont.)
BlueChoice HealthPlan(available in all South Carolina counties)
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Physician copays Plan pays 100 percent of allowable
charges after copay $15 PCP and OB-GYN copay $30 specialist copay $35 urgent care copay
(cont.)
BlueChoice HealthPlan(available in all South Carolina counties)
• Human organ transplant lifetime maximum $350,000 per person
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• Tobacco cessation benefits available Free for subscribers and covered dependents, age 18 and older
Contact Free & Clear at:
866-Quit-4-Life (866-784-8454)
(cont.)
BlueChoice HealthPlan(available in all South Carolina counties)
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Retail Pharmacy (up to 31-day supply)
• $7 generic brand • $35 preferred brand • $55 non-preferred brand• $100 specialty pharmaceuticals
Mail Order (up to 90-day supply)
• $14 generic brand• $70 preferred brand• $110 non-preferred brand
Network Only
BlueChoice HealthPlan(available in all South Carolina counties)
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CIGNA HMO
Insurance Education Part #2
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Features• Annual deductible: none• HMO pays 80 percent of allowable charges
• Subscriber pays 20 percent --applies toward coinsurance maximum
CIGNA HMO (available in all South Carolina counties except: Abbeville, Aiken, Barnwell, Edgefield, Greenwood, Laurens, McCormick and Saluda)
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(cont.)
• Coinsurance maximum $2,000 for individual $4,000 for family Most an individual or family will pay for covered services
Includes inpatient/outpatient hospital copays• $250 outpatient hospital copay• $500 inpatient hospital copay
CIGNA HMO (available in all South Carolina counties except: Abbeville, Aiken, Barnwell, Edgefield, Greenwood, Laurens, McCormick and Saluda)
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(cont.)
• $100 emergency room copay HMO pays 100 percent of allowable charges after subscriber pays copay
CIGNA HMO(available in all South Carolina counties except: Abbeville, Aiken, Barnwell, Edgefield, Greenwood, Laurens, McCormick and Saluda)
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• Plan pays 100 percent of allowable charges after subscriber pays $15 PCP and OB-GYN copay $30 specialist copay $30 outpatient mental health and
substance abuse copay $50 urgent care copay
(cont.)
CIGNA HMO(available in all South Carolina counties except: Abbeville, Aiken, Barnwell, Edgefield, Greenwood, Laurens, McCormick and Saluda)
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Short-term rehabilitation therapy and chiropractic services $30 specialist copay Limit per year -- 20 visits
(cont.)
CIGNA HMO(available in all South Carolina counties except: Abbeville, Aiken, Barnwell, Edgefield, Greenwood, Laurens, McCormick and Saluda)
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Mail Order (up to 90-day supply)
• $14 generic brand • $50 preferred brand • $100 non-preferred brand
Network Only
Retail Pharmacy (up to 31-day supply)
$7 generic brand $25 preferred brand $50 non-preferred brand
CIGNA HMO(available in all South Carolina counties except: Abbeville, Aiken, Barnwell, Edgefield, Greenwood, Laurens, McCormick and Saluda)
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• Beginning January 1, 2008, available to subscribers and covered dependents
• Free• Enroll
Call 866-417-7848 or Visit CIGNA’s Web site
www.myCIGNA.com
CIGNA Quit TodaySM Tobacco Cessation Program
CIGNA HMO(available in all South Carolina counties except: Abbeville, Aiken, Barnwell, Edgefield, Greenwood, Laurens, McCormick and Saluda)
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Strength and ResilienceSM Stress Management Program• Free to subscribers and covered dependents
• Includes: Stress risk assessment Up to six coaching sessions during first six months
Unlimited calls to coach
CIGNA HMO(available in all South Carolina counties except: Abbeville, Aiken, Barnwell, Edgefield, Greenwood, Laurens, McCormick and Saluda)
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• To enroll Call 866-417-7848 or Visit CIGNA’s Web site:
www.myCIGNA.com
(cont.)
CIGNA HMO(available in all South Carolina counties except: Abbeville, Aiken, Barnwell, Edgefield, Greenwood, Laurens, McCormick and Saluda)
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Active Employee Health Plan Premiums
Insurance Education Part #2
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SHP
Savings Plan
SHP Standard
Plan
You Pay
Employee only $ 9.28 $ 93.46 $ 0.00
Employee/ spouse $ 72.56 $237.50 $144.04 Employee/ children $ 20.28 $142.46 $ 49.00 Full family $108.56 $294.58 $201.12
CI GNA
HMO
You Pay Blue-Choice
HMO You Pay
Employee only $136.30 $36.30 $129.60 $29.60 Employee/ spouse $390.94 $290.94 $380.50 $280.50 Employee/ children $288.66 $188.66 $282.14 $182.14
Full family $577.34 $477.34 $566.48 $466.48
Active Employee Monthly Health Premiums
Active Employee Monthly Health Premiums