Medical Insurance
With Cigna medical plans, you have the flexibility to see any doctor or specialist within the Cigna Open Access Plus network without needing a referral from a physician. As a plan participant, you are not obligated to select a primary care physician. These benefits apply exclusively to In-Network providers. To locate a provider, please visit www.cigna.com. Deductibles and out-of-pocket expenses accrue on a calendar year basis, running from January 1 to December 31.
Cigna Medical Plans
$1,000 Plan OAP PPO
$2,500 Plan OAP Plan PPO
$3,500 Plan OAP with HSA
PLAN BASICS
Calendar Year Deductible (Individual | Family) Coinsurance Percentage (Plan | Member)
$1,000 | $3,000
$2,500 | $7,500
$3,500 | $7,000
80% | 20%
80% | 20%
100% | 0%
Maximum Out-of-Pocket Limit (Individual | Family) Copays and Coinsurance Office Visit (Primary Care | Specialist) Telehealth Visit: MDLive Preventive Care Diagnostic Lab Diagnostic X-Ray Advanced Imaging Urgent Care Facility Emergency Room Inpatient Hospital Outpatient Facility Out of Network Calendar Year Deductible (Individual | Family) Coinsurance Percentage (Plan | Member) Maximum Out-of-Pocket Limit (Individual | Family) Retail (Up to 30-Day Supply) Genetic Drugs Preferred Brand Name Drugs Non-Preferred Brand Names
$4,000 | $12,000
$5,500 | $14,700
$3,500 | $7,000
$30 | $60
$30 | $60
Deductible Deductible Deductible Deductible Deductible Deductible Deductible Deductible Deductible
$30
$30
$0 Most services $0 Most services $0 Most services
$0 Most services $0 Most services $0 Most services
$0 Most services
Deductible , CoinsuranceDeductible , Coinsurance
$75
$75
$500, Coinsurance
$500, Coinsurance
Deductible , CoinsuranceDeductible , Coinsurance Deductible , CoinsuranceDeductible , Coinsurance
$2,000 | $6,000
$5,000 | $15,000
$7,000 | $14,000
60% | 40%
60% | 40%
70% | 30%
$28,000 | $56,000
$28,000 | $56,000
$28,000 | $56,000
$0
$0
Deductible Deductible Deductible Deductible
$50 $100 $150
$50 $100 $150
Specialty Retail
Mail Order (Up to 90-Day Supply)
Up to 3 times the retail cost
This brochure is a brief overview of your plan. It does not list all benefits, nor does it list all exclusions and limitations. For more complete information, please refer to the Certificate, or the employer’s Master Policy. 8
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