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SAIC Benefits Summary Plan Description Health & Welfare Benefits for You and Your Family

Comparing the SAIC Medical Plans

The chart below provides some basic plan information about the SAIC self-insured plans.

Download the SAIC Medical Plans Table (28k)

SAIC Medical Plans
  MEDPLUS MEDBASIC CATASTROPHIC OUT OF AREA
  NETWORK* OUT-OF-NETWORK** NETWORK* OUT-OF-NETWORK** NETWORK* OUT-OF-NETWORK**  

Annual Deductible

$250 per person

$600 per person

$2,000 per person

$350 per person

Common Accident Deductible

$250

$600

$2,000

$350

Special Accident Benefit

Deductible waived for first $500 in eligible expenses due to an accident. Expenses must be incurred within 90 days of an accident.

N/A

N/A

N/A

N/A

N/A

Annual Out-Of-Pocket Maximum

$1,250 per person plus deductible

$3,750 per person plus deductible

$2,500 per person plus deductible

$7,500 per person plus deductible

$5,000 per person, $10,000 per family, deductible included

$5,000 per person, $10,000 per family, deductible included

$2,000 per person plus deductible

Office Visits - Primary Care Provider (PCP)

$15 copay then plan pays 100%

Plan pays 65% after deductible

$25 copay then plan pays 100%

Plan pays 60% after deductible

Plan pays 70% after deductible

Plan pays 50% after deductible

Plan pays 80% after deductible

Office Visits - Specialist

$25 copay then plan pays 100%

Plan pays 65% after deductible

$35 copay then plan pays 100%

Plan pays 60% after deductible

Plan pays 70% after deductible

Plan pays 50% after deductible

Plan pays 80% after deductible

Emergency Room

$50 copay per visit (waived if admitted) then plan pays 85% after deductible. For non-emergency use of the emergency room, plan pays 50% after deductible.

$50 copay per visit (waived if admitted) then plan pays 65% after deductible. For non-emergency use of the emergency room, plan pays 50% after deductible.

$50 copay per visit (waived if admitted) then plan pays 80% after deductible. For non-emergency use of the emergency room, plan pays 50% after deductible.

$50 copay per visit (waived if admitted) then plan pays 60% after deductible. For non-emergency use of the emergency room, plan pays 50% after deductible.

Plan pays 70% after deductible. For non-emergency use of the emergency room, plan pays 50% after deductible.

Plan pays 50% after deductible

$50 copay per visit (waived if admitted) then pays 80% after deductible

Hospital Admission

$200 copay per admission then plan pays 85% after deductible

$200 copay per admission then plan pays 65% after deductible

$200 copay per admission then plan pays 80% after deductible

$200 copay per admission then plan pays 60% after deductible

Plan pays 70% after deductible

Plan pays 50% after deductible

$200 copay per admission then plan pays 80% after deductible

Periodic Health Assessments (PCP)

$15 copay then plan pays 100%; up to age 65: 1 exam every 24 months; age 65 or older: 1 exam every 12 months. Deductible waived for associated x-ray and lab services

Not covered

$25 copay then plan pays 100%; up to age 65: 1 exam every 24 months; age 65 or older: 1 exam every 12 months. Deductible waived for associated x-ray and lab services

Not covered

Not covered

Not covered

Plan pays 80% after deductible; up to age 65: 1 exam every 24 months; age 65 or older: 1 exam every 12 months

Well-Child Care (PCP)

$15 copay then plan pays 100%; up to age 1: maximum 7 visits; age 1 – 2: maximum 2 visits; age 3 – 17: maximum 1 visit. Deductible waived for associated x-ray and lab services

Not covered

$25 copay then plan pays 100%; up to age 1: maximum 7 visits; age 1 – 2: maximum 2 visits; age 3 – 17: maximum 1 visit. Deductible waived for associated x-ray and lab services

Not covered

Not covered

Not covered

Plan pays 80% after deductible

Lab and X-Ray

Plan pays 85% after deductible for non-routine lab & x-ray services provided outside the office visit

Plan pays 65% after deductible

Plan pays 80% after deductible for non-routine lab & x-ray services provided outside the office visit

Plan pays 60% after deductible

Plan pays 70% after deductible

Plan pays 50% after deductible

Plan pays 80% after deductible

Outpatient Surgery

Plan pays 85% after deductible

Plan pays 65% after deductible

Plan pays 80% after deductible

Plan pays 60% after deductible

Plan pays 70% after deductible

Plan pays 50% after deductible

Plan pays 80% after deductible

Routine Mammograms

Plan pays 85% – Deductible waived

Plan pays 65% after deductible

Plan pays 80% – Deductible waived

Plan pays 60% after deductible

Plan pays 70% – Deductible waived

Plan pays 50% after deductible

Plan pays 80% after deductible

Routine Pap Smears

Plan pays 85% – Deductible waived

Plan pays 65% after deductible

Plan pays 80% – Deductible waived

Plan pays 60% after deductible

Plan pays 70% – Deductible waived

Plan pays 50% after deductible

Plan pays 80% after deductible

PSA/DRE

Over age 40

Plan pays 85% – Deductible waived

Plan pays 65% after deductible

Plan pays 80% – Deductible waived

Plan pays 60% after deductible

Plan pays 70% – Deductible waived

Plan pays 50% after deductible

Plan pays 80% after deductible

Skilled Nursing Facility

Plan pays 85% after deductible for up to 60 days per condition

Plan pays 65% after deductible for up to 60 days per condition

Plan pays 80% after deductible for up to 60 days per condition

Plan pays 60% after deductible for up to 60 days per condition

Plan pays 70% after deductible for up to 60 days per condition

Plan pays 50% after deductible for up to 60 days per condition

Plan pays 80% after deductible for up to 60 days per condition

Home Health Care (maximum visits combined with skilled nursing care and private duty nursing)

Plan pays 100% for up to 100 visits per year, up to 4 hours = 1 visit

Plan pays 100% for up to 100 visits per year, up to 4 hours = 1 visit

Plan pays 100% for up to 100 visits per year, up to 4 hours = 1 visit

Plan pays 100% for up to 100 visits per year, up to 4 hours = 1 visit

Plan pays 100% for up to 100 visits per year, up to 4 hours = 1 visit

Plan pays 100% for up to 100 visits per year, up to 4 hours = 1 visit

Plan pays 100% for up to 100 visits per year, up to 4 hours = 1 visit

Private Duty Nursing (maximum visits combined with Home Health Care benefit)

Plan pays 100% for up to 100 visits per year, up to 8 hours = 1 visit

Plan pays 65% after deductible

Plan pays 100% for up to 100 visits per year, up to 8 hours = 1 visit

Not covered

Plan pays 100% for up to 100 visits per year, up to 8 hours = 1 visit

Not covered

Plan pays 100% for up to 100 visits per year, up to 8 hours = 1 visit

Hospice Care (up to 30 days per lifetime for inpatient and $10,000 per lifetime for outpatient)

Plan pays 85% – Deductible waived

Plan pays 65% – Deductible waived

Plan pays 80% – Deductible waived

Plan pays 60% – Deductible waived

Plan pays 70% – Deductible waived

Plan pays 50% – Deductible waived

Plan pays 80% – Deductible waived

Outpatient Rehabilitation —Physical and Speech (as medically necessary)

Plan pays 85% after deductible

Plan pays 65% after deductible

Plan pays 80% after deductible

Plan pays 60% after deductible

Plan pays 70% after deductible

Plan pays 50% after deductible

Plan pays 80% after deductible

Durable Medical Equipment

Plan pays 85% after deductible

Plan pays 65% after deductible

Plan pays 80% after deductible

Plan pays 60% after deductible

Plan pays 70% after deductible

Plan pays 50% after deductible

Plan pays 80% after deductible

Mental Health and Substance Abuse – Outpatient (provided by CIGNA Behavioral Health)***

$30 copay then plan pays 100%

Plan pays 50%; up to max $30 per visit and 50 visits per year

$30 copay then plan pays 100%

Plan pays 50%; up to max $30 per visit and 50 visits per year

Plan pays 70% after deductible

Plan pays 50% after deductible

$30 copay then plan pays 100%

Mental Health and Substance Abuse – Inpatient (provided by CIGNA Behavioral Health)***

Plan pays 85%

Plan pays 50%

Plan pays 80%

Plan pays 50%

Pre-certification is required. Plan pays 70% after deductible

Plan pays 50% after deductible

Plan pays 80%

Most Other Services

Plan pays 85% after deductible

Plan pays 65% after deductible

Plan pays 80% after deductible

Plan pays 60% after deductible

Plan pays 70% after deductible

Plan pays 50% after deductible

Plan pays 80% after deductible

Prescription Drugs:

Retail Pharmacy (up to a 30-day supply)

Copays:

$10 generic
$20 brand formulary
$35 brand non-formulary

Not covered

Copays:

$15 generic $25 brand formulary $35 brand non-formulary

Not covered

Plan pays 70% after deductible

Not covered

Copays:

$10 generic
$20 brand formulary
$35 brand non-formulary

Mail Order (up to a 90-day supply)

2x retail pharmacy copay

2x retail pharmacy copay

Plan pays 70% after deductible

2x retail pharmacy copay

Lifetime Benefit Maximum (Combined In-Network & Out-Of-Network)

$2 million per person (Lifetime maximum benefit is combined for all SAIC self-insured plans.)

* Covered services received from a network provider will be paid based on the negotiated rate.

** Covered services received from an out-of-network provider will be paid based on the reasonable and customary (R&C) limit.

*** Deductible is waived for these services. Copays and coinsurances do not apply to the out-of-pocket maximum.