2023 | VEO Employee Benefit Guide

CIGNA OPEN ACCESS MANAGED CHOICE POS

BENEFIT

IN-NETWORK

OUT-OF-NETWORK

Annual Deductible - per calendar year

Individual:

$7,000 $14,000 $7,000 $14,000

Individual:

$7,000 $14,000 $7,000 $14,000

Family:

Family:

Out-of-pocket Maximum - per calendar year ( Does include the annual deductible )

Individual:

Individual:

Family:

Family:

Coinsurance

Carrier 100% Employee 0%

Carrier 70% Employee 30%

Preventive Care Adult physical exams (Age 22 & Over) Well-child care (Up to age 22) Well-woman care Mammograms Outpatient Care Primary care physician office visits Specialist office visits Outpatient facility surgery Diagnostic Laboratory tests, X-rays Diagnostic Complex Imaging (MRI)

No charge No charge No charge No charge

30% after deductible No charge 30% after deductible 30% after deductible 30% after deductible 30% after deductible 30% after deductible 30% after deductible 30% after deductible

0% after deductible 0% after deductible 0% after deductible 0% after deductible 0% after deductible

Hospital Care Physician’s and surgeon’s services

0% after deductible

30% after deductible

Emergency Care At hospital emergency room (waived if admitted) Urgent Center

0% after deductible 0% after deductible

$75 copay 30% after deductible

Maternity Services Prenatal care Hospital services for mother and child

0% after deductible 0% after deductible

30% after deductible 30% after deductible

Mental Health Inpatient Outpatient

0% after deductible 0% after deductible

30% after deductible 30% after deductible

Spinal Treatment

0% after deductible

30% after deductible

Durable Medical Equipment

0% after deductible

30% after deductible

Prescriptions National Performance Network Retail Pharmacy (30 day supply) Mail Order (90 day supply)

Medical Plan Deductible Applies for All Tiers

30% after copay $10 Tier 1, $30 Tier 2, $50 Tier 3 Covered In-Network Only

$10 Tier 1, $30 Tier 2, $50 Tier 3 $20 Tier 1, $60 Tier 2, $100 Tier 3

For additional information, please refer to your detailed plan summary. In the event of a discrepancy, the carrier Plan Document shall prevail.