2025-2026 Employee Benefit Guide - Huntington UFSD (6.26.25)

Medical Benefits

800.555.5555 www.myCIGNA.com

Dental Benefits

800.555.5555 www.GuardianAnytime.com

CIGNA Healthcare is Huntington UFSD medical carrier for 2025/2026. Participating providers can be found by calling 800.555.5555 or using CIGNA’s website at www.myCIGNA.com. With CIGNA’s Open Access Plus plans, you do not need to select a Primary Care Physician and you do not need referrals .

Guardian is Huntington UFSD dental carrier for 2025/2026. Participating providers can be found by using Guardian’s Provider Online Search at www.GuardianAnytime.com.

OPEN ACCESS PLUS

MDG PLAN

PPO PLAN

BENEFIT

IN-NETWORK

OUT-OF-NETWORK

BENEFIT

IN-NETWORK

OUT-OF-NETWORK

IN-NETWORK ONLY

Annual Deductible

Individual: None Family: None

Individual: $500 Family: $1,000

% of usual, customary and reasonable fees for the services

Coinsurance

100%

70%

Out-of-Pocket Maximum

Individual: $1,500 Family: $3,000

Individual: $1,500 Family: $3,000

Annual Deductible (Waived for Preventive)

Individual: $0 Family: $0

Individual: $50 Family: $150

$5 Office visit copay

Lifetime Maximum

Unlimited

Unlimited

Benefit Maximum

Unlimited

Annual: $1,500 Combined In- and Out-of-Network

Outpatient Care Primary care physician office visits Specialist office visits Outpatient facility surgery

Preventive Services Cleaning (prophylaxis) Fluoride Treatments Oral Exams Sealants (per tooth) X-Rays Basic Services Fillings Perio Surgery Periodontal Maintenance Root Canal

Covered at 100% after $20 copay Covered at 100% after $30 copay Covered at 100%

70% after deductible 70% after deductible 70% after deductible

100% no deductible 100% no deductible 100% no deductible 100% no deductible 100% no deductible 90% no deductible 90% no deductible 90% no deductible 90% no deductible 90% no deductible 90% no deductible

100% no deductible 100% no deductible 100% no deductible 100% no deductible 100% no deductible 80% after deductible 80% after deductible 80% after deductible 80% after deductible 80% after deductible 80% after deductible

No charge No charge No charge $6 No charge $13 $140 $16 $90-$140 $17 $37-$60

Preventive Care

Covered at 100%

70% deductible does not apply

Hospital Care

Covered at 100%

70% after deductible

Emergency Care At hospital emergency room Urgent Care

Covered at 100% after $100 copay Covered at 100% after $50 copay

Covered at 100% after $100 copay Covered at 100% after $50 copay

Simple Extractions Surgical Extractions

Prescriptions* Retail Pharmacy (30 day supply) Generic Preferred Brand Non-Preferred Brand Mail Order (90 day supply) Generic Preferred Brand Non-Preferred Brand

$15 copay $25 copay $50 copay $30 copay $50 copay $100 copay

Major Services Bridges & Dentures Inlays, Onlays, Veneers Single Crowns

70% after deductible

60% no deductible 60% no deductible 60% no deductible

50% after deductible 50% after deductible 50% after deductible

$330-$365 $225-$265 $275

Not covered

Orthodontic Services

50% $1,500 lifetime maximum Combined In- and Out-of-Network Child coverage only up to the age of 19

$2,425 copay Adults & Children

REMINDER: Precertification is required for hospital admissions and select outpatient services based on your plan. If you use a health care professional in Cigna’s network, your doctor will work with Cigna to arrange for precertification. If you use a health care professional who does not participate with Cigna, you are responsible for obtaining precertification. If you and your doctor require the brand name drug instead of the generic, your doctor will need to indicate Dispense As Written (DAW) on your prescription to avoid paying the higher cost. Please note that balance billing applies when utilizing Out-of-Network services. For additional plan information, please refer to your detailed plan design provided by the carrier. In the event of a discrepancy, the carrier Plan Document shall prevail.

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

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

QUESTIONS? Call BenefitsVIP at 866.000.0000

QUESTIONS? Call BenefitsVIP at 866.000.0000

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