Benefit Guide - People

MEDICAL BENEFITS

BENEFIT

IN-NETWORK

OUT-OF-NETWORK

IN-NETWORK

OUT-OF-NETWORK

IN-NETWORK

OUT-OF-NETWORK

Annual Deductible (Calendar Year)

Individual : $3,000 Family: $6,000

Individual: $6,000 Family: $12,000

Individual: $1,600 Family: $3,200

Individual: $3,200 Family: $6,400

Individual: $1,000 Family: $2,000

Individual: $2,000 Family: $4,000

Coinsurance

Cigna 70%/EE 30%

Cigna 50%/EE 50%

Cigna 100%/EE 0%

Cigna 80%/EE 20%

Cigna 100%/EE 0%

Cigna 80%/EE 20%

Out-of-Pocket Maximum

Individual: $6,000 Family: $12,000

Individual: $12,000 Family: $24,000

Individual: $7,500 Family: $15,000

Individual: $14,000 Family: $28,000

Individual: $7,300 Family: $14,600

Individual: $14,600 Family: $29,200

Adult Preventive Care Adult Annual Physical Exam Well-Child Care

100% deductible waived 100% deductible waived 100% deductible waived

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

100% deductible waived 100% deductible waived 100% deductible waived

80% after deductible 80% after deductible 80% after deductible

100% deductible waived 100% deductible waived 100% deductible waived

80% after deductible 80% after deductible 80% after deductible

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

$25 copay after deductible $50 copay after deductible

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

$25 copay after deductible $50 copay after deductible 100% after deductible Facility: $500 copay Office visit: $250 copay

80% after deductible 80% after deductible 80% after deductible 80% after deductible

$15 copay $30 copay 100% after deductible Facility: $400 copay Office visit: $200 copay

80% after deductible 80% after deductible 80% after deductible 80% after deductible 80% after deductible

70% after deductible 70% after deductible

Outpatient Surgery

70% after deductible

50% after deductible

100% after deductible

80% after deductible

$200 copay

$300 copay then 80%

Emergency Care Ambulance Emergency Room

70% after deductible 70% after deductible

70% after deductible 70% after deductible

100% after deductible $350 copay after deductible

100% after deductible $350 copay after deductible

100% $250 copay

100% $250 copay

Urgent Care

70% after deductible

50% after deductible

$100 copay after deductible

80% after deductible

$50 copay

80% after deductible

Inpatient Hospital Care

70% after deductible

50% after deductible

100% after deductible

80% after deductible

$400 copay

$500 copay then 80%

Maternity Care Prenatal and Post-natal care Hospital services for mother & child

100% after deductible 70% after deductible

50% after deductible 50% after deductible

100% after deductible 100% after deductible

80% after deductible 80% after deductible

100% deductible waived $400 copay

80% after deductible 80% after deductible

PRESCRIPTION DRUG COVERAGE

Drug Deductible

Plan Deductible Applies Individual: $3,000 Family: $6,000

Plan Deductible Applies Individual: $6,000 Family: $12,000

Plan Deductible Applies Individual: $1,600 Family: $3,200

Plan Deductible Applies Individual: $3,200 Family: $6,400

Waived for Generic Individual: $250 Family: $500

Waived for Generic Individual: $250 Family: $500

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

$10 copay $45 copay $65 copay

80% after deductible 80% after deductible 80% after deductible

$15 copay $45 copay $65 copay

80% after deductible 80% after deductible 80% after deductible

$10 copay $45 copay $65 copay

80% after deductible 80% after deductible 80% after deductible

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

$20 copay $90 copay $130 copay

$30 copay $90 copay $130 copay

80% after deductible 80% after deductible 80% after deductible

$20 copay $90 copay $130 copay

80% after deductible 80% after deductible 80% after deductible

80% after deductible 80% after deductible 80% after deductible

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

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