Benefit Guide - Circles

MEDICAL BENEFIT

BENEFIT

IN-NETWORK

IN-NETWORK ONLY

IN-NETWORK

OUT-OF-NETWORK

Annual Deductible (Calendar Year)

Individual:

$4,000 $8,000

Individual:

$2,000 $4,000

Individual :

$3,000 $6,000

Individual:

$3,000 $6,000

Family:

Family:

Family:

Family:

Coinsurance

Cigna 80%/EE 20%

Cigna 90%/EE 10%

Cigna 80%/EE 20%

Cigna 60%/EE 40%

Out-of-Pocket Maximum

Individual:

$5,000 $10,000

Individual:

$4,500 $9,000

Individual:

$5,000 $10,000

Individual:

$7,000 $14,000

Family:

Family:

Family:

Family:

Adult Preventive Care Adult Annual Physical Exam Well-Child Care

Covered at 100% Covered at 100% Covered at 100%

Covered at 100% Covered at 100% Covered at 100%

Covered at 100% Covered at 100% Covered at 100%

30% after deductible 30% after deductible 30% after deductible

Doctor’s Office Visits Primary Care Physician Specialist Virtual Care Outpatient Laboratory X-ray Complex Imaging (CT, PET Scans, MRI)

$40 copay $60 copay $40 copay

$30 copay $50 copay $30 copay

$30 copay $50 copay $30 copay

30% after deductible 30% after deductible In-Network Only 30% after deductible 30% after deductible 30% after deductible

20% after deductible 20% after deductible 20% after deductible

Covered at 100% Covered at 100% Covered at 100%

Covered at 100% Covered at 100% Covered at 100%

Outpatient Surgery

$750 copay per admission then 20% after deductible

$750 copay per admission then 10% after deductible

$750 copay per admission then 20% after deductible

40% after deductible

Emergency Care Ambulance Emergency Room

20% after deductible $500 copay

10% after deductible $500 copay

20% after deductible $500 copay

20% after deductible $500 copay

Urgent Care

$50 copay

$50 copay

$50 copay

30% after deductible

Inpatient Hospital Care

$750 copay per admission then 20% after deductible

$750 copay per admission then 10% after deductible

$750 copay per admission then 20% after deductible

40% after deductible

Maternity Care Hospital services for mother & child

$750 copay per admission then 20% after deductible

$750 copay per admission then 10% after deductible

$750 copay per admission then 20% after deductible

40% after deductible

PRESCRIPTION DRUG COVERAGE

Drug Deductible Waived for Tier 1

Individual:

$100 $200

Individual:

$100 $200

Individual:

$100 $200

Individual:

N/A N/A

Family:

Family:

Family:

Family:

Retail (30 day supply) Tier 1 Tier 2 Tier 3

$15 copay $35 copay $75 copay

$15 copay $35 copay $75 copay

$15 copay $30 copay $60 copay

In-Network Only

Mail Order (90 day supply) Tier 1 Tier 2 Tier 3

$38 copay $88 copay $188 copay

$38 copay $88 copay $188 copay

$38 copay $75 copay $150 copay

In-Network Only

BI -WEEKLY CONTRIBUTIONS

Employee Employee + Spouse Employee + Child(ren) Employee + Family

$187.88 $621.68 $540.33 $708.62

$220.48 $691.84 $603.12 $785.19

$273.92 $799.67 $701.56 $965.03

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

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