MEDICAL INSURANCE
Gracepoint offers three medical plans through Cigna. To find participating providers go to www.cigna.com and click on “Find a Doctor”, choose the appropriate provider type. The Low and Mid plans use the Cigna Open Access Plus (IN) and High plan provider network uses the Cigna Open Access Plus (Choice) Network.
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 Open Access Plus – In Network
MID Open Access Plus – In Network
HIGH Open Access Plus – Choice
IN-NETWORK: Plan or Calendar Year Basis
Calendar Year
Calendar Year
Calendar Year
Deductible (Individual/Family)
$3,500 / $7,000
$2,250 / $4,500
$1,500 / $3,000
Coinsurance
70% / 30%
80% / 20%
80% / 20%
Maximum Out-of-Pocket (Individual/Family)
$7,350, $14,700
$5,000 / $10,000
$4,000 / $8,000
Maximum Out-of-Pocket Includes
Deductible, Coinsurance & Copayments Deductible, Coinsurance & Copayments Deductible, Coinsurance & Copayments
Lifetime Medical Maximum
Unlimited
Unlimited
Unlimited
PREVENTIVE CARE:
Wellness Immunizations Mammography/Colonoscopy COPAYMENTS: Telemedicine (24/7 – 365 days a year) Primary Physician Office Visits – No Referral Required
Covered 100%
Covered 100%
Covered 100%
$40 Copayment
$30 Copayment
$25 Copayment
$40 Copayment
$30 Copayment
$25 Copayment
Specialist Visits
$50 Copayment
$30 Copayment
$25 Copayment
Inpatient Hospital
Deductible & Coinsurance
Deductible & Coinsurance
Deductible & Coinsurance
Outpatient Surgery
Deductible & Coinsurance
Deductible & Coinsurance
Deductible & Coinsurance
Emergency Room
Deductible & Coinsurance
$150 Copayment
$100 Copayment
Urgent Care
$100 Copayment
$50 Copayment
$50 Copayment
OUTPATIENT DIAGNOSTIC SERVICES: Lab Services
Covered 100%
Covered 100%
Covered 100%
X-Ray Services
Covered 100%
Covered 100%
Covered 100%
Complex Diagnostic
Deductible & Coinsurance
Deductible & Coinsurance
Deductible & Coinsurance
PRESCRIPTIONS: Retail (30 day supply)
$20 / $55 / $100
$10 / $40 / $70
$10 / $35 / $60
Mail Order (90 day supply)
3 X retail
3 X retail
3 X retail
OUT-OF-NETWORK: Deductible (Individual/Family)
In-Network Only
In-Network Only
$3,000 / $6,000
Maximum Out-of-Pocket (Individual/Family)
In-Network Only
In-Network Only
$10,000/ $20,000
Lifetime Medical Maximum
In-Network Only
In-Network Only
Unlimited
Coinsurance
In-Network Only
In-Network Only
60% / 40%
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