Benefits for 2025
Medical
Cigna PPO Plan
In Network (National)
What you pay
Out of Network
Preventive Care
0$ Copay
40% after deductible
Office Visit: PCP / Specialist
$25 Copay / $40 Copay 40% after deductible
$250 Copay then 20% after deductible (Copay waived if admitted)
Emergency Room
Urgent Care
$25 Copay
40% after Deductible
Complex Imaging (Outpatient)
20% after Deductible 40% after Deductible
Lab & X-Ray (Outpatient)
20% after Deductible 40% after Deductible
Inpatient Hospital
20% after Deductible 40% after Deductible
Outpatient Surgery
20% after Deductible 40% after Deductible
Deductible (Individual / Family)
$1,250 / $3,750
$1,500 / $4,500
Out-of-Pocket Max (Individual / Family)
$4,000 / $8,000
$11,500 / $23,000
Rx Copays (Retail or Mail Order Supply)
$10 / $25 / $45
Not Covered
Notes: Plan offers access to Cigna’s Open Access Plus National Network of doctors/hospitals All copays, deductibles, & coinsurance apply towards the out-of-pocket max Out-of-Network services are paid based on allowable charges. Member may be responsible for paying the balance of the billed amount above that rate (commonly known as “balance billing”)
Employee Cost Per Pay Period (26)
PPO Plan
Employee Only
$253.39
Employee + 1
$600.00
Employee + Family
$800.00
* Member may be responsible for any amount over the allowed amount
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2025 Employee Benefit Guide
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