Aetna 2014

* Some Associates are covered by special networks in certain areas of the country. If you participate in the Aetna plans, and live in Minnesota, you will be covered by the Patient Choice Network.
If you participate in the UnitedHealthcare plans, and live in Minnesota or North Dakota, you will be covered by the Medica network.
** Out-of-network charges are based on the carrier’s “Allowable Charge”, which is based on Medicare Reimbursement levels. Out-of-network charges are subject to Balance Billing. Review the
Glossary of Terms for a further explanation of Balance Billing.
Below you will find an overview of the three medical plan options available to you. For more information,
please refer to the Summary Plan Descriptions (SPDs) located at www.cognizantbenefits.com.
MEDICAL BENEFITS
Plan 90 Plan 80 CDHP
Aetna Choice POS II* or UnitedHealthcare Choice Plus* Aetna Choice POS II* or UnitedHealthcare Choice Plus* Cigna
In-Network Out-Of-Network** In-Network Out-Of-Network** In-Network Out-Of-Network**
Plan Year Out-Of-Pocket Maximum
Individual/Family
(excluding deductible)
$2,000/$6,000 $2,500/$7,500 $3,000/$9,000 $5,000/$15,000 $5,000/$12,700 $7,500/$22,500
Plan Year Deductible
Individual/Family $100/$300 $500/$1,500 $500/$1,500 $2,000/$6,000 $2,500/$7,500 $6,050/$12,100
Coinsurance 90% after deductible 70% after deductible 80% after deductible 50% after deductible 100% 50%
Lifetime Maximum Unlimited Unlimited Unlimited
Routine Medical Care
Office Visit $25 copay 70% after deductible $35 copay 50% after deductible Deductible 50% after deductible
Specialist Visit $40 copay 70% after deductible $50 copay 50% after deductible Deductible 50% after deductible
Swift MD Visit $0 copay N/A $0 copay N/A 100% N/A
Prenatal Care 100% 70% after deductible 100% 50% after deductible Deductible 50% after deductible
Physical Exam 100% 70% after deductible 100% 50% after deductible 100%, deductible waived 50% after deductible
Maternity $40 copay 70% after deductible $50 copay 50% after deductible Deductible 50% after deductible
Routine Well-Baby Checkups 100% 70% after deductible 100% 50% after deductible 100%, deductible waived 50% after deductible
X-Ray and Lab 90% after deductible 70% after deductible 80% after deductible 50% after deductible Deductible 50% after deductible
Hospital
Inpatient Copay
$250 per confinement:
then 90%
$250 per confinement:
then 70% after deductible
$250 per confinement:
then 80%
$250 per confinement:
then 50% after deductible
Deductible 50% after deductible
Emergency Room Facility $100 copay: then 90% (deductible waived) $100 copay: then 80% (deductible waived) Deductible 50% after deductible
Emergency Room Provider 90% after deductible 70% after deductible 80% after deductible 50% after deductible Deductible 50% after deductible
Ambulance Services
(Emergency Transport Only)
100% (emergency transport only) 100% (emergency transport only) Deductible 50% after deductible
Urgent Care Center
Office Visit $40 copay 70% after deductible $50 copay 50% after deductible Deductible 50% after deductible
Substance Abuse / Mental Health
Office Visit $25 copay 70% after deductible $35 copay 50% after deductible Deductible 50% after deductible
Inpatient
$250 per confinement;
then 90%
$250 per confinement;
then 70% after deductible
$250 per confinement;
then 80%
$250 per confinement;
then 50% after deductible
Deductible 50% after deductible
Prescription Drug, Retail
(30 Day Supply)
Cigna Cigna Cigna
Generic $5 copay Not covered $15 copay Not covered $5 copay after deductible Not covered
Preferred Brand $35 copay Not covered $50 copay Not covered $35 copay after deductible Not covered
Non-Preferred Brand $50 copay Not covered $85 copay Not covered $50 copay after deductible Not covered
Mail Order Drugs
90 Day Supply 2x retail copay 2x retail copay 2x retail copay after deductible
Employee Contribution (Monthly)
Employee Only $93 $61.50 $44
Employee + Child(ren) $275 $160 $110
Employee + Spouse/Domestic Partner $275 $160 $110
Family $412 $270 $192