MEDICAL
The Concrete Company offers the following plans through Cigna. Please reference the Summary Plan Description for more details. Insurance Carrier: Cigna Medical Insurance Medical Plan: HDHP POS In-Network: Office Visit Copay - Primary Care Deductible; then 100% Coinsurance $25 Copay Office Visit Copay - Specialist Care Deductible; then 100% Coinsurance $50 Copay Urgent Care Copay Deductible; then 100% Coinsurance $60 Copay Emergency Room Care (waived if admitted) Deductible; then 100% Coinsurance $150 Copay; then 80% Coinsurance Preventative Visit Copay 100% Coinsurance; No Deductible 100% Coinsurance; No Deductible Coinsurance 100% 80% Employee Deductible $6,300 $2,500 Family Deductible $12,600 $7,500 Employee Out-of-Pocket Max $6,300 $6,600 Family Out-of-Pocket Max $12,600 $13,200 Inpatient Hospital Deductible; then 100% Coinsurance Deductible; then 80% Coinsurance Outpatient Hospital or Facility Deductible; then 100% Coinsurance $150 Copay; Deductible; then 80% Out-of-Network: Coinsurance 70% 60% Employee Deductible $10,000 $5,000 Family Deductible $20,000 $15,000 Employee Out-of-Pocket Max $18,900 $19,800 Family Out-of-Pocket Max $37,800 $39,600 Prescription Drugs: ( 30 Day Supply) Tier 1 - Generic Deductible; then 100% Coinsurance $15 Copay Tier 2 - Preferred Deductible; then 100% Coinsurance $40 Copay; after Rx Deductible Tier 3 - Non-Preferred Deductible; then 100% Coinsurance $75 Copay; after Rx Deductible Tier 4 - Specialty Deductible; then 100% Coinsurance 20%; after Rx Deductible RATES: Weekly Monthly Weekly Monthly Employee Only $40.15 $174.00 $94.62 $410.00 Employee + Spouse $121.15 $525.00 $199.62 $865.00 Employee + Child(ren) $109.62 $475.00 $180.00 $780.00 Family $173.08 $750.00 $282.69 $1,225.00
6 | The Concrete Company Benefit Guide
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