VOXX 2024 OE Guide - FINAL

BENEFIT

IN-NETWORK ONLY

Annual Deductible Covered dependents within a family must meet the family deductible together before coinsurance applies for all members

Individual: $2,750 Family: $6,750 (Family Aggregate)

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

Individual: $5,320 Individual with a Family: $6,750 Family: $13,300 (Embedded)

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Coinsurance

Cigna Pays 100%

Preventive Care Adult and Child (including immunizations)

No charge

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

Covered 100% after deductible Covered 100% after deductible Covered 100% after deductible

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

Covered 100% after deductible

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

Covered 100% after deductible

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

Covered 100% after deductible

Maternity Care Inpatient Outpatient

Covered 100% after deductible Covered 100% after deductible

Mental Health Inpatient Outpatient

Covered 100% after deductible Covered 100% after deductible

Prescription Drugs Calendar Year Deductible

Subject to plan deductible

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

$20/$40/$60/$75

$500/$100/$150/$75 Included in Plan Out-of-Pocket Maximum

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