The level of benefits you will receive depends on where you choose to receive care. In the Piedmont PRN Plan, you can receive care from in-network providers, but you will not be covered if you choose to see out-of-network providers. You pay for the full cost of health care services, including prescription drugs, until you reach the in-network deductible/out-of-pocket maximum.
To locate a provider, use one of the following options:
MyHealth360 plan members: Open the Castlight mobile app and select “Find Care.” If you do not have the mobile app, you can register online at mycastlight.com/piedmont.
Note: Not all physician offices located on Piedmont campuses are in the Piedmont Clinic.
When you select an out-of-network provider, you will incur the highest out-of-pocket expenses. Providers and facilities are those not included in the Cigna Open Access Plus Network.
This example shows coverage using in-network providers.
Key Plan Details
You pay the full cost of care until you meet the in-network deductible/out-of-pocket maximum; then, the plan pays the full cost of care for the rest of the year.
The deductibles are “embedded” (i.e., the plan begins to pay if one covered family member meets the in-network, employee only deductible).
In emergencies, coverage is provided at the in-network level, regardless of where you receive the care.
Still not sure how the plan works? Scroll through these examples:
Meet Jill
Plan: Piedmont PRN Plan Who’s Covered: Family Premium: $1,296.00 (monthly) Out-of-Network Coverage: Emergency only Deductible/Out-of-Pocket Maximum: $17,100 (in-network only: Cigna LocalPlus Network)
Situation:
Jill and her family have a very unhealthy year. Her husband receives multiple surgeries (triggering the individual family deductible embedded in the plan – $8,550). His in-network follow-up care is covered at 100%. The rest of the family exceeds the $17,100 deductible/out-of-pocket maximum, so their in-network care is covered in full for the rest of 2023.
Meet William
Plan: Piedmont PRN Plan Who’s Covered: Employee Only Premium: $103.00 (monthly) Out-of-Network Coverage: Emergency only Deductible/Out-of-Pocket Maximum: $8,550 (in-network only: Cigna LocalPlus Network)
Situation:
William is on vacation and gets into an accident. His one-day, out-of-state hospital stay costs $5,000 (emergencies are covered at the highest benefit level). Remember, William pays the full, upfront cost for any health care services until he reaches the deductible/out-of-pocket maximum. If he needs additional care, William will need to pay $3,550 more before the plan pays for in-network care in full for the rest of 2023.
Martha wants to continue receiving care from her cancer doctor, who is not in the Cigna LocalPlus Network. She will pay the full, upfront cost of care for all out-of-network services. Martha can offset some of these costs with rollover HRA funds.
Meet Jill
Plan: Piedmont PRN Plan Who’s Covered: Family Premium: $1,296.00 (monthly) Out-of-Network Coverage: Emergency only Deductible/Out-of-Pocket Maximum: $17,100 (in-network only: Cigna LocalPlus Network)
Situation:
Jill and her family have a very unhealthy year. Her husband receives multiple surgeries (triggering the individual family deductible embedded in the plan – $8,550). His in-network follow-up care is covered at 100%. The rest of the family exceeds the $17,100 deductible/out-of-pocket maximum, so their in-network care is covered in full for the rest of 2023.
Meet William
Plan: Piedmont PRN Plan Who’s Covered: Employee Only Premium: $103.00 (monthly) Out-of-Network Coverage: Emergency only Deductible/Out-of-Pocket Maximum: $8,550 (in-network only: Cigna LocalPlus Network)
Situation:
William is on vacation and gets into an accident. His one-day, out-of-state hospital stay costs $5,000 (emergencies are covered at the highest benefit level). Remember, William pays the full, upfront cost for any health care services until he reaches the deductible/out-of-pocket maximum. If he needs additional care, William will need to pay $3,550 more before the plan pays for in-network care in full for the rest of 2023.
Martha wants to continue receiving care from her cancer doctor, who is not in the Cigna LocalPlus Network. She will pay the full, upfront cost of care for all out-of-network services. Martha can offset some of these costs with rollover HRA funds.
Meet Jill
Plan: Piedmont PRN Plan Who’s Covered: Family Premium: $1,296.00 (monthly) Out-of-Network Coverage: Emergency only Deductible/Out-of-Pocket Maximum: $17,100 (in-network only: Cigna LocalPlus Network)
Situation:
Jill and her family have a very unhealthy year. Her husband receives multiple surgeries (triggering the individual family deductible embedded in the plan – $8,550). His in-network follow-up care is covered at 100%. The rest of the family exceeds the $17,100 deductible/out-of-pocket maximum, so their in-network care is covered in full for the rest of 2023.
Prescription Drugs
Prescription drug coverage through Cigna is provided automatically when you enroll in the Piedmont PRN Plan. If your medication is not on the no-cost generic preventive medications listing, you will you pay the full cost until you reach your deductible/out-of-pocket maximum. Any prescription drug costs you pay for on your own will contribute towards your annual deductible/out-of-pocket maximum.
When it comes to prescriptions, there are five easy guidelines to follow:
Use generic drugs when you can. Be sure to ask your physician or pharmacist if a generic substitute is available—it could save you money!
Take advantage of preventive medication at no cost to you. To help you maintain a steady treatment regimen, certain preventive medicines are paid at 100% with no deductible when you visit an in-network pharmacy. This includes many diabetes, cholesterol, blood pressure and other select medication categories.
When you use the broad Cigna/Express Scripts network of retail pharmacies, including Piedmont pharmacies, Oconee Drugs, Walgreens, Kroger, and Walmart retail pharmacies, you can get a 90-day supply of your medication for just two times your 30-day copay amount.
Consider using Cigna’s Home Delivery Pharmacy mail-order option for your maintenance medications—for 2.5x the 30-day copay for a 90-day supply, rather than receiving refills at a retail pharmacy. Review the Home Delivery FAQs for more details.
Remember to explore drug options with your physician to avoid costly name-brand and specialty drug copays that may not be necessary. If you must use brand or specialty drugs, to help offset the cost, take advantage of manufacturer coupons.
You must meet a $150 (per member) annual deductible for brand-name prescriptions (preferred and non-preferred) before benefits begin.
This is a separate deductible from the medical plan deductible.
You will not need to meet this deductible for generic prescriptions.
Piedmont Direct Pharmacy
We offer life-changing specialty pharmacy services designed to simplify every aspect of your care. From obtaining financial assistance, to navigating through your insurance benefits, coordinating with providers, and managing refills, Piedmont Specialty Pharmacy patient liaisons are ready to help you and your family.
Our team can answer and address insurance-related questions and conduct prior authorizations for complex, rare and chronic medical conditions that require specialized medication therapy.
In-Region Remote (residing in Georgia, Alabama and South Carolina, including System Office and Physician Enterprise [Piedmont Clinic, PHI and PMCC] employees)
Out-of-Region Remote (All other U.S. states; including System Office and Physician Enterprise [Piedmont Clinic, PHI and PMCC] employees)
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Children include your or your spouse’s/domestic partner’s natural children, legally‑adopted children, legal wards and stepchildren.
Employee + Spouse/Domestic Partner
If your spouse/domestic partner has medical coverage available through his/her employer, he/she is not eligible to enroll in Piedmont’s medical coverage.
Your spouse/domestic partner is eligible for coverage under the Piedmont benefit plans* if they are:
Covered by Medicaid
Covered by Medicare
Covered by Retiree Medical
Self-employed
Employed by a company that doesn’t subsidize the cost of medical insurance
When you enroll your dependents in our benefit programs, you will be required by an independent verifier to provide documentation of your dependents’ eligibility.
Domestic Partner Coverage is available for medical benefits. You will be required to complete a Domestic Partner Affidavit.
* Piedmont benefits may be considered secondary. Please refer to your Summary Plan Description to determine which plan is primary.
Coordination of Benefits
If you and your spouse/domestic partner both cover your dependent children under your own medical benefits, your benefits will coordinate to ensure duplicate payments are not made.
The primary plan will pay its full benefit first. When considering the secondary plan, the Piedmont plan will make additional payments that are due up to the amount it would have paid if it were the primary plan. Benefits will not be duplicated.
The primary plan for dependents is determined by whose birthday falls first in the calendar year (employee or spouse/domestic partner).
Our benefit plans will halt processing a claim until the employee verifies that additional coverage is or is not available. Once verified, the claim processing will continue.
Medicare is always the primary plan for domestic partners who are eligible for Medicare, even if the domestic partner is not enrolled in Medicare. Piedmont benefits are considered secondary. The secondary plan will make payments that are due up to the amount it would have paid, but not greater than the balance due.
Example: Coordination of Benefits
Jack is a staff nurse with Piedmont. He is married to Liz, and they have one child, Sam.
Jack covers Sam under the Piedmont PRN Plan. Liz is employed and has her own medical coverage through her employer. Liz also covers Sam on her medical plan.
Sam goes to the doctor on February 15. The doctor files the claim under both Jack’s and Liz’s medical plans.
The primary plan for dependents is determined by whichever parent’s birthday falls first in the calendar year.
Jack’s birthday is January 30 and Liz’s birthday is March 5.
Primary Medical Claim: Jack’s medical coverage, under the Piedmont PRN Plan, will pay the medical claim as primary (as if this was the only coverage available).
Secondary Medical Claim: Liz’s medical coverage, under her employer, will pay the claim as secondary, per her plan rules.
Where can I get high-quality, low-cost care?
For non-emergency care, get a virtual visit on your computer or smartphone from anywhere. You have 24/7 access to board-certified doctors for a copay. Also, get same-day care for minor injury or illness at all Piedmont-branded urgent care centers for a copay. Most locations are open seven days a week with extended hours.
Is support available for diabetes and nutrition issues?
Yes. MyHealth360 members (regardless of what medical plan they choose) receive coverage on diabetic products, supplies and durable medical equipment. You can also attend unlimited pre-diabetes and diabetes education classes and counseling sessions and three nutrition consultations per year—with all costs covered by the plan. A referral from your primary care physician is required.
Cigna offers a network of national ancillary providers to ensure convenient access to cost-effective, quality durable medical equipment (DME) in the home setting. In addition to these national vendors, locally based participating DME providers are available. Check the Cigna provider directory to find a local provider.
Legal / Disclaimer
This website is not inclusive of all situations and is provided for informational purposes only. It is not intended to be an official legal document. If there are conflicts between the website and IRS regulations, the member handbook, or the Summary Plan Description (SPD), IRS regulations, the member handbook, and the SPD will govern.
