VOXX 2024 OE Guide - FINAL

BENEFIT

IN-NETWORK

OUT-OF-NETWORK

IN-NETWORK ONLY

Annual Deductible Covered dependents within a family only need to satisfy the individual deductible before coinsurance applies Out-of-Pocket Maximum Covered dependents within a family only need to satisfy the individual out-of-pocket maximum before coinsurance applies

Individual: $500 Family: $1,250 (Embedded) Individual: $1,500 Family: $3,750 (Embedded)

Individual: $1,000 Family: $2,500 (Embedded) Individual: $4,000 Family: $10,000 (Embedded)

Individual: $500 Family: $1,250 (Embedded) Individual: $1,500 Family: $3,750 (Embedded)

Coinsurance

You Pay 10% Cigna Pays 90%

You Pay 30% Cigna Pays 70%

You Pay 10% Cigna Pays 90%

Preventive Care Adult and Child (including immunizations)

No charge

30% after deductible

No charge

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

$30 copay (deductible waived) $50 copay (deductible waived) 10% after deductible

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

$30 copay (deductible waived) $50 copay (deductible waived) 10% after deductible

Inpatient Care (Hospitalization, physical therapy, surgery, mental health, substance abuse, skilled nursing facility)

10% after deductible

30% after deductible

10% after deductible

Diagnostic Procedures (Lab tests, X-rays, MRI/MRAs, PET/CAT Scans)

10% after deductible

30% after deductible

10% after deductible

Emergency Care Ambulance when medically necessary Hospital emergency room (waived if admitted) Urgent Care

10% after deductible $150 copay (deductible waived) $50 copay (deductible waived)

10% after deductible $150 copay (deductible waived) $50 copay (deductible waived)

10% after deductible $150 copay (deductible waived) $50 copay (deductible waived)

Maternity Care Inpatient Outpatient Mental Health Inpatient Outpatient

10% after deductible $30 copay (deductible waived)

30% after deductible 30% after deductible

10% after deductible $30 copay (deductible waived)

10% after deductible $30 copay (deductible waived)

30% after deductible 30% after deductible

10% after deductible $30 copay (deductible waived)

Prescription Drugs Calendar Year Deductible

None $20/$40/$60/$75

N/A $20/$40/$60/$75

Retail Pharmacy (30-day or Retail 90 at certain pharmacies) Generic/Preferred Brand/Non-Preferred Brand/Specialty Mail Order (90-day supply; 30 days for Specialty) Generic/Preferred Brand/Non-Preferred Brand/Specialty) Pharmacy Out-of-Pocket Maximum

Not Covered

$50/$100/$150/$75

$50/$100/$150/$75

Individual: $2,500 Family: $5,000

Individual: $2,500 Family: $5,000

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