Benefits for 2025
Medical
Cigna HMO Plan
What you pay
In Network (HMO Southern California Network)
Preventive Care
No Charge
Office Visit: PCP / Specialist (Referral Required to see a Specialist)
$20 Copay / $20 Copay
Emergency Room
$200 Copay (waived if admitted)
Urgent Care
$25 Copay
Complex Imaging (Outpatient)
$250 Copay after Deductible
Lab & X-Ray (Outpatient)
Plan pays 100%
Inpatient Hospital
$1,000 Copay after Deductible
Outpatient Surgery
$500 Copay after Deductible
Deductible (Individual / Family)
$500 / $1,000
Out-of-Pocket Max (Individual / Family)
$3,000 / $6,000
Rx Copays (Retail or Mail Order Supply)
$10 / $25 / $45
Notes: Plan requires referrals to see any type of specialist All employees must use doctors/hospitals that participate within the Cigna HMO Network All copays, deductibles, & coinsurance apply towards the out-of-pocket max
Employee Cost Per Pay Period (26)
HMO Plan
Employee Only Employee + 1
$60.00 $189.00 $286.00
Employee + Family
* 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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