MEDICAL INSURANCE
M.E. Wilson Company offers two medical plans through Cigna. To find participating providers go to www.cigna.com and click on “Find a Doctor”, choose the appropriate plan type, then, narrow down your search based on location and provider type. The plan type you should select is OAP (Open Access Plus).
The chart below provides a brief overview of the medical plans. This chart is intended only to highlight the benefits available and should not be relied upon to fully determine your coverage. If the below illustration of benefits conflicts in any way with the Summary Plan Description (SPD), the SPD shall prevail. It is recommended that you review your exact description of services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.
Low Option HSA OAP Plan
High Option OAPIN Plan
IN-NETWORK:
Plan Year / Contract Year Basis
Calendar Year
Calendar Year
Deductible (Individual / Family)
$1,500 / $3,000
$1,500 / $4,500
Maximum Out-of-Pocket (Individual / Family)
$4,500 / $9,000
$4,500 / $9,000
Deductible, Coinsurance, & Copays
Deductible, Coinsurance, & Copays
Out-of-Pocket Max Includes
Lifetime Maximum
Unlimited
Unlimited
Coinsurance
80% / 20%
80% / 20%
Routine Preventive Services
Wellness
Covered 100%
Covered 100%
Immunizations
Mammography/Colonoscopy
CO-PAYS
Referral required
No
No
Office Visits Consultations for Illness / Injury
Deductible & Coinsurance
$30 copay
Specialist Visits
Deductible & Coinsurance
$55 copay
Inpatient Hospital
Deductible & Coinsurance
Deductible & Coinsurance
Outpatient Surgery
Deductible & Coinsurance
Deductible & Coinsurance
Emergency Room
Deductible & Coinsurance
$250 copay
Urgent Care
Deductible & Coinsurance
$60 copay
OUTPATIENT DIAGNOSTIC SERVICES
Lab Services (Freestanding Lab)
Deductible & Coinsurance
Covered 100%
X-Ray Services (Freestanding Lab)
Deductible & Coinsurance
Covered 100%
Complex Diagnostic
Deductible & Coinsurance
$250 copay
PRESCRIPTIONS
(Once Deductible is Met)
Retail (30 day supply)
$10 / $50 / $80
$10 / $30 / $50
Mail Order (90 day supply)
3 x retail
3 x retail
OUT-OF-NETWORK
Deductible (Individual / Family)
$5,000 / $10,000
Not Available – In Network Only
Maximum Out-of-Pocket (Individual / Family)
$10,000 / $20,000
Not Available – In Network Only
Lifetime Maximum
Unlimited
Not Available – In Network Only
Coinsurance
60% / 40%
Not Available – In Network Only
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