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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