Onion Benefits Guide 2024 FINAL

PPO PLAN

BENEFIT

IN-NETWORK (CIGNA PPO)

OUT-OF-NETWORK

Annual Deductible A member of the family only needs to meet the individual deductible before the plan will pay 100% of their covered expenses.

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

Individual: $7,000; Family: $14,000

Out-of-Pocket Maximum Includes Coinsurance/Copays.

A member of the family only needs to meet the individual out-of-pocket maximum before the plan will pay 100% of their covered expenses.

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

Individual: $8,000; Family: $16,000

Coinsurance

0% (Employee Pays)

10% (Employee Pays)

Preventive Care Adult Preventive Care (including screenings and immunizations) Adult Annual Physical Exam Well-Child Care (including immunizations) Outpatient Care Primary care physician office visits Specialist office visits Outpatient facility surgery Diagnostic Testing Routine (Lab and X-Ray) Complex Imaging (MRI, MRA, CAT, PET) Emergency Care Ambulance when medically necessary At hospital emergency room Urgent Care

0%

10%*

$30 $50 0%*

10%* 10%* 10%*

0%* 0%*

10%* 10%*

0%* $150 (waived if admitted) $75

0%* $150 (waived if admitted) 10%*

Inpatient Hospital Per admission

0%*

10%*

Prescription Drug Out-of-Pocket Maximum

$1,000 person/$3,000 Family

Retail Pharmacy (30 day supply) Generic/Preferred Brand/Non-Preferred Brand/Specialty Mail Order (90 day supply) Generic/Preferred Brand/Non-Preferred Brand/Specialty

$10/$35/$75/$150

$20/$70/$150/$150 (Specialty 30-day supply)

Semi-Monthly Contributions Employee Only Employee + Spouse Employee + Child(ren) Employee + Family

$45.00 $165.00 $165.00 $217.50

* after deductible

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