NETWORK:
MEDICAL COVERAGE
Insurance Carrier:
Angle Health Medical Insurance: Cigna PPO Network
Medical Plan:
$1,500 Copay Plan
$3,400 HDHP Plan
In-Network: Primary Care Visits
$30 Copay
Deductible; then 20% Coinsurance
Specialist Care Visits
$70 Copay
Deductible; then 20% Coinsurance
Urgent Care
$70 Copay
Deductible; then 20% Coinsurance
Emergency Room Care
Deductible; then $350 Copay
Deductible; then 20% Coinsurance
Preventative Visit Copay
$0
$0
Diagnostic Testing (X-Ray / Blood Work)
Deductible; then 0% Coinsurance
Deductible; then 20% Coinsurance
Advanced Imaging
Deductible; then 0% Coinsurance
Deductible; then 20% Coinsurance
Plan Coinsurance
100%
80%
Employee Deductible
$1,500
$3,400
Family Deductible
$3,000
$6,800
Employee Out-of-Pocket Max
$3,500 (includes deductible)
$5,000 (includes deductible)
Family Out-of-Pocket Max
$7,000 (includes deductible)
$10,000 (includes deductible)
Inpatient Hospital
Deductible; then 0% Coinsurance
Deductible; then 20% Coinsurance
Outpatient Hospital or Facility
Deductible; then 0% Coinsurance
Deductible; then 20% Coinsurance
Out-of-Network Plan Coinsurance
50%
50%
Employee Deductible
$5,000
$6,600
Family Deductible
$10,000 $10,000 $20,000
$13,200 $10,000 $20,000
Employee Out-of-Pocket Max
Family Out-of-Pocket Max
Prescription Drugs 30-day supply Tier 1 - Generic
$0
Deductible; then 20% Coinsurance Deductible; then 20% Coinsurance Deductible; then 20% Coinsurance Deductible; then 20% Coinsurance
Tier 2 - Preferred
$10 $60
Tier 3 - Non-Preferred
Tier 4 - Specialty
Deductible; then 20% Coinsurance
Employee Semi-Monthly Deduction Employee Only
$0.00
$0.00
Employee + Spouse Employee + Child(ren)
$324.19 $279.84 $605.06
$219.63 $182.72 $453.45
Family
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