ONLINE BENEFITS DIRECTORY
HIGH DEDUCTIBLE HEALTH PLAN
Piedmont Health Services, Inc. offers health insurance beginning the first of the month after thirty days of employment to all full-time employees and part-time employees working more than twenty four hours a week.
What is Covered
For details on coverage, visit the following Summary Benefit Coverage (SBC) at the following link:
Medical Plan Overview for High Deductible Plan
|Benefit||PHS DISCOUNT||CIGNA NETWORK||OUT OF NETWORK|
|-Employee & Dependents||$3,000||$4,000||$6,000|
|OUT OF POCKET MAXIMUM|
|Employee & Dependents||$6,000||$6,850||$12,000|
|Preventive Care||Covered in full||Covered in full||50% after deductible|
|Primary Care||20% after $1,500 deductible||20% after $2,000 or $4,000 deductible||50% after $3,000 or $6000 deductible|
|Specialist Visit||N/A||20% after $2,000 or $4,000 deductible||50% after $3,000 or $6000 deductible|
|Inpatient Hospital||N/A||20% after $2,000 or $4,000 deductible||50% after $3,000 or $6000 deductible|
|Urgent Care||N/A||20% after $2,000 or $4,000 deductible||50% after $3,000 or $6000 deductible|
|Emergency Room||N/A||20% after $2,000 or $4,000 deductible||50% after $3,000 or $6000 deductible|
|-Tier 1 Generic||10% after $1,500 deductible||20% after $2,000 deductible||Not covered|
|-Tier 2 Preferred Brand||10% after $1,500 deductible||20% after $2,000 deductible||Not Covered|
|-Tier 3 Non-preferred Brand||10% after $1,500 deductible||20% after $2,000 deductible||Not Covered|
|-Tier 5 Specialty||20% after deductible||20% after $2,000 deductible||Not Covered|
NOTE: This is a convenient summary. This is intended for information purposes only. It is not a complete listing of the benefits, exclusions, terms or conditions of the Certificate of Insurance. The actual contract provisions prevail. Please read your booklet carefully.
CIGNA is the preferred service provider for employees of Piedmont Health. Go to myCigna Registration to Fingerprint Access to see the variety of providers available to you.
Cost of Benefit
|PLAN||EMPLOYEE ONLY||EMPLOYEE & SPOUSE||EMPLOYEE & CHILD||EMPLOYEE & CHILDREN||EMPLOYEE & FAMILY|
These are current costs and are subject to change from time to time.
The Piedmont Healthcare Services HR Department can be reached at firstname.lastname@example.org
Director of Human Resources
919-537-7487 – Office
919-537-0469 – FAX
Cobra Continuation Information: www.dol.gov
Online Forms & Flyers
Cigna Flyer Instructions for Finding a Doctor
Cigna One Guide Benefits Overview without Pharmacy Customer Flyer
Approved Prescription List (ESI Basic Formulary)
2020 ESI Standard Plus Generic Preventive Medications
2020 ESI – ACA Drug List Standard Offering
Copy of ESI ACA Preventive Meds
Medical Claim Form
Cigna Total Behavioral Health Happify Customer Flyer
Answers by Cigna for Amazon Alexa Customer Flyer
iPrevail Customer Flyer
Heathly Babies Cigna Maternity Healthy Start Brochure
Healthy Rewards Healthy Choices Healthy Discounts Customer Flyer
Click on the following link To find which Tier your Medication falls under:
Health Insurance Portability and Accountability Act (HIPAA) of 1996 Notice
Special Enrollment Information
This information is being provided to you pursuant to the Health Insurance Portability and Accountability Act (HIPAA) of 1996. It contains some special information regarding your rights to enroll for coverage under the medical plan in the future. This information is very important if you are currently declining coverage under the medical plan for yourself or for any of your dependents. We are required to provide you with this notice in order to comply with HIPAA.
If You are Declining Coverage Now
If you have decided to decline coverage for yourself or for any of your dependents (including your spouse), you may be able to enroll yourself and/or your dependents in this plan later, under some circumstances, without waiting for an open enrollment period.
Special Enrollment Allowed
You can enroll yourself and your dependents in this plan without waiting for an open enrollment period if:
1. You decline coverage under this plan because you have other health care coverage, then you lose the other coverage because you are no longer eligible or because the employer failed to pay the required premium. In such cases, you must enroll in this plan within 30 days after losing the other coverage.
2. You decline coverage under this plan and then a new dependent is added to your family due to marriage, birth, adoption, or placement or adoption. In such cases, you must enroll in this plan (or add your new dependent) within 30 days after the marriage, birth, adoption, or placement for adoption.
Any request must be consistent with the change in family status. For example, the birth or adoption of a child would permit enrollment in or change to family coverage.
Other Late Entrants
If you decide not to enroll in this plan now and then want to enroll later, you must qualify for special enrollment as described above. If you do not qualify for special enrollment, you will have to wait until an open enrollment period.
For more information, please contact your human resources administrator.
Women’s Health and Cancer Rights Act (WHCRA) Notice
Re: Health Plan Coverage for Reconstructive Breast Surgery under The Women’s Health and Cancer Rights Act of 1998
Since 1998, Congress has required that all health plans cover reconstructive surgery following a mastectomy. When a covered individual receives benefits for a mastectomy and decides to have breast reconstruction based on consultation between the attending physician and the patient, the health plan must cover:
reconstruction of the breast on which the mastectomy was performed;
surgery and reconstruction of the other breast to produce symmetrical appearance; and
prostheses and physical complications of all stages of mastectomy, including lymphedema.
Our plan complies with the Federal mandate. This coverage will be subject to all other Plan provisions.
Rosalyn R. Freeman
Director of Human Resources