5 | 2024 CNO Benefits Open Enrollment Guide CNO offers the choice of four health plan options - three High Deductible Health Plan (HDHP) Options and a Traditional PPO Plan Option. CNO's HDHP Options are compatible with a Health Savings Account (HSA). Medical Option Overview All options cover the same services and are supported by the Anthem BlueCross Blue Shield National BlueCard® network. OPTION DETAILS OPTION A (Higher Deductible) OPTION B (Medium Deductible) OPTION C (Lowest Deductible) OPTION D (Traditional PPO) Preventive Care 100% payable by the Plan when provided by an in-network provider/facility (including annual exam, routine mammogram, PAP tests, prostate screenings, immunizations, etc.) In Network Annual Deductibles $4,000 / Associate $6,000 / Limited family $8,000 / Family $3,000 / Associate $4,500 / Limited family $6,000 / Family $2,000 / Associate $3,000 / Limited family $4,000 / Family $3,000 / Associate $4,500 / Limited family $6,000 / Family Coinsurance In-network: 80% of allowable charges covered after deductible Copays Services are covered subject to deductible, coinsurance and out of pocket maximum. PCP Office Visit: $35 Specialty Office Visit: $70 Urgent Care: $100 Emergency Room: $500 Prescription Drugs *There are no out-of- network benefits for prescription drugs Preventive Maintenance: Generics are 100% payable by the Plan when filled at Walgreens, Meijer, Walmart, Kroger, Costco Retail Stores or Costco Mail Order. Deductible is waived on preventive maintenance brand medications when filled at Walgreens, Meijer, Walmart, Kroger, Costco Retail, or Costco Mail Order. Tier 1 through 3 & Specialty: After deductible you pay: Tier 1: 20% up to $15 Tier 2: 40% up to $50 Tier 3: 60% up to $100 Specialty: 60% up to $300 No Deductible Tier 1: 20% up to $15 Tier 2: 40% up to $50 Tier 3: 60% up to $100 Specialty: 60% up to $300 In Network Annual Out of Pocket Maximum (1) (2) $7,000 / Associate $10,500 / Limited family $14,000 / Family $6,000 / Associate $9,000 / Limited family $12,000 / Family $4,500 / Associate $6,750 / Limited family $9,000 / Family $6,000 / Associate $9,000 / Limited family $12,000 / Family (1) Embedded individual out-of-pocket maximum increasing to ACA maximum of $9,450. No Individual will have an out-of-pocket maximum exceeding $9,450. (2) Services provided by an out of network provider are subject to a separate higher deductible, coinsurance and out of pocket maximum. Medical Options
