PPO

Eligibility

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 PPO

BenefitPHS DISCOUNTCIGNA NETWORKOUT OF NETWORK
DEDUCTIBLE
-Employee OnlyN/A$1,000$2,000
-Employee & DependentsN/A$2,000$6,000
OUT OF POCKET MAXIMUM
-Employee Only$2,000$2,500$10,000
Employee & Dependents$4,000$5,000$20,000
COVERAGE
Preventive CareCovered in fullCovered in full50% after deductible
Primary Care$10 copay$35 copay50% after $3,000 or $6000 deductible
Specialist VisitN/A$70 copay50% after $3,000 or $6000 deductible
Inpatient HospitalN/A20% after $2,000 or $4,000 deductible50% after $3,000 or $6000 deductible
Urgent CareN/A$75 copay50% after $3,000 or $6000 deductible
Emergency RoomN/A$300 copay$300 copay
PRESCRIPTION DRUGS
-Tier 1 Generic$0$10 copayNot covered
-Tier 2 Preferred Brand$10 copay$25 copayNot Covered
-Tier 3 Non-preferred Brand$20 copay$50 copayNot Covered
-Tier 5 Specialty$80 copay$250 copayNot 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.

Preferred providers

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

PLANEMPLOYEE ONLYEMPLOYEE & SPOUSEEMPLOYEE & CHILDEMPLOYEE & CHILDRENEMPLOYEE & FAMILY
PPO$26.92$378.80$172.71$328.00$673.44
HDHP---$299.41$124.00$256.23$550.38

These are current costs and are subject to change from time to time.

Cost of Benefit 2021

PLANEMPLOYEE ONLYEMPLOYEE & SPOUSEEMPLOYEE & CHILDEMPLOYEE & CHILDRENEMPLOYEE & FAMILY
PPO$37.04$436.13$202.43$378.61$770.51
HDHP---$338.49$139.49$289.50$623.21

These are current costs and are subject to change from time to time.

Continued coverage after I stop working

You may continue coverage for you and your legal dependents at your own expense. Certain conditions apply. You will be provided with the proper forms, information, and costs upon leaving your employment with Piedmont Health.

Other Resources

 

The Piedmont Healthcare Services HR Department can be reached at hrteam@piedmonthealth.org

Online Booklets and Flyers

Click on the following link To find which Tier your Medication fall into:

www.express-scripts.com

SPECIAL NOTICES

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.

 WHCRA

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.

 

HUMAN RESOURCES

(Office) 919-537-7503
(Fax) 919-537-0469
hrteam@piedmonthealth.org

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