NETWORK:
MEDICAL COVERAGE
Insurance Carrier:
Angle Health Medical Insurance: Cigna PPO Network
Medical Plan:
Base Plan
Buy-Up Plan
HDHP w/ HSA
In-Network: Primary Care Visits
$25 Copay
$25 Copay
Deductible; then 0% Coinsurance
Specialist Care Visits
$75 Copay
$75 Copay
Deductible; then 0% Coinsurance
Urgent Care
$85 Copay
$85 Copay
Deductible; then 0% Coinsurance
Emergency Room Care
Deductible; then $300 Copay
Deductible; then $300 Copay Deductible; then 0% Coinsurance
Preventative Visit Copay
$0
$0
$0
Diagnostic Testing (X-Ray / Blood Work)
$25 Copay
$25 Copay
Deductible; then 0% Coinsurance
Advanced Imaging
Deductible; then 0% Coinsurance Deductible; then 0% Coinsurance Deductible; then 0% Coinsurance
Plan Coinsurance
100%
80%
100%
Employee Deductible
$7,000
$5,000
$7,000
Family Deductible
$14,000
$10,000
$14,000
Employee Out-of-Pocket Max
$9,000 (includes deductible)
$7,000 (includes deductible)
$7,000 (includes deductible)
Family Out-of-Pocket Max
$18,000 (includes deductible)
$14,000 (includes deductible)
$14,000 (includes deductible)
Inpatient Hospital
Deductible; then 0% Coinsurance Deductible; then 20% Coinsurance Deductible; then 0% Coinsurance
Outpatient Hospital or Facility Deductible; then 0% Coinsurance Deductible; then 20% Coinsurance Deductible; then 0% Coinsurance Out-of-Network Plan Coinsurance 50% 50% 50% Employee Deductible $14,000 $10,000 $14,000 Family Deductible $28,000 $20,000 $28,000 Employee Out-of-Pocket Max $18,000 $14,000 $14,000 Family Out-of-Pocket Max $36,000 $28,000 $28,000 Prescription Drugs 30-day supply Tier 1 - Generic $20 $20 Deductible; then 0% Coinsurance Tier 2 - Preferred $60 $60 Deductible; then 0% Coinsurance Tier 3 - Non-Preferred $85 $85 Deductible; then 0% Coinsurance Tier 4 - Specialty Deductible; then 20% Coinsurance Deductible; then 20% Coinsurance Deductible; then 0% Coinsurance Employee Bi-Weekly Deduction Employee Only $87.92 $110.81 $60.41 Employee + Spouse $383.12 $444.00 $409.02 Employee + Child(ren) $330.80 $368.04 $379.54 Family $620.92 $656.11 $594.19
6 | Spring Harbor 2025 Benefits Guide
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