The Cigna Select PPO plan provides a range of benefits to cover your health care needs, including prescription drugs, immunizations, vaccines, and hospital stays.
If you live in Hawaii, you are eligible to enroll in the Kaiser Hawaii HMO medical plan.
Eligibility
SelectTime employees. Seasonal employees are included in a 12-month measurement period to determine health care benefit eligibility.
How It Works
How to Enroll
See how to enroll in benefits.
How to Get Started
Cigna Select PPO Summary of Benefits
| Plan Feature | Cigna Select PPO In-Network |
Cigna Select PPO Out-of-Network |
|---|---|---|
|
Plan-Year Deductible |
$750 individual |
$1,500 individual1 |
|
Plan-Year |
$3,250 individual |
$6,500 individual2 |
| Coinsurance | Plan pays 80% after deductible | Plan pays 60% after deductible |
| Preventive Care | Plan pays 100% | $30 copay, then plan pays 60% |
| Office Visits (PCP/specialist) |
$30 copay, then plan pays 100% | $30 copay, then plan pays 60% |
| Inpatient Care | Plan pays 80% after deductible | Plan pays 60% after deductible |
| Outpatient Care | Plan pays 80% after deductible | Plan pays 60% after deductible |
| Emergency Room (waived if admitted) |
$250 copay | $250 copay |
1 After each eligible member meets his or her individual deductible, covered expenses for that family member will be paid based on the benefit level that are within reasonable and customary charges. Or once the family deductible is met, covered expenses for each family member will be paid based on the benefit level that are within reasonable and customary charges.
2 After each eligible member meets his or her individual out-of-pocket maximum, the plan will pay 100% of their covered expenses that are within reasonable and customary charges. Or once the family out-of-pocket maximum is met, the plan will pay 100% of each eligible member’s covered expenses that are within reasonable and customary charges.
Cigna Select PPO Paycheck Deductions
| Coverage Level | Per-Paycheck Cost |
|---|---|
| Employee Only | $69 |
| Employee + Spouse/Domestic Partner | $224 |
| Employee + Children | $172.25 |
| Employee + Family | $275.75 |
Kaiser Hawaii HMO Summary of Benefits
| Plan Feature | Kaiser Hawaii HMO In-Network |
Kaiser Hawaii HMO Out-of-Network |
|---|---|---|
|
Plan-Year Deductible |
$0 individual |
Not Covered |
|
Plan-Year |
$2,500 individual |
Not Covered |
| Coinsurance | N/A | Not Covered |
| Preventive Care | No Charge | Not Covered |
| Office Visits (PCP/specialist) |
$20 copay | Not Covered |
| Inpatient Care | Plan pays 90% | Not Covered |
| Outpatient Care | Plan pays 90% | Not Covered |
| Emergency Room | $100 copay | Limited initial visit only. Must notify KP within 48 hours if admitted to a non-plan provider |
1 After each eligible member meets his or her individual out-of-pocket maximum, the plan will pay 100% of their covered expenses. Or once the family out-of-pocket maximum is met, the plan will pay 100% of each eligible member’s covered expenses.
Kaiser Hawaii HMO Prescription Benefits
| Kaiser Hawaii HMO | |
|---|---|
| Annual Out-of-Pocket Maximum | Prescription amounts count toward medical plan out-of-pocket maximum |
| Retail (per 30-day supply) | |
| Preferred Generic | $10 copay |
| Preferred Brand | $35 copay |
| Non-preferred Brand | $35 copay |
| Mail Order (per 90-day supply) | |
| Preferred Generic | $20 copay |
| Preferred Brand | $70 copay |
| Non-preferred Brand | $70 copay |
Kaiser Hawaii HMO Paycheck Deductions
| Coverage Level | Per-Paycheck Cost |
|---|---|
| Employee Only | $12.75 |
| Employee + Spouse/Domestic Partner | $127.58 |
| Employee + Children | $104.62 |
| Employee + Family | $242.42 |
If you are a resident of Hawaii and you plan to waive coverage you must make the election to waive during your enrollment and you must complete the Form HC-5 Notification to Employer to waive coverage and submit to Employee Benefits.
Common Questions
How do I enroll in medical benefits?
Resources
Form HC-5 Notification to Employer to Waive Coverage
Where to Get Help
HR Connect
Phone
1-800-819-1620
Visit website
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Cigna
Plan/Group Number
#3331771
Phone
1-800-244-6224
Visit website
Kaiser Hawaii HMO (Hawaii residents only)
Plan/Group Number
10763
Phone
1-808-432-5955
Visit website