MEDICAL PLAN
SUMMARY OF COVERAGE
EPO Low Plan
EPO Mid Plan
EPO High Plan
(Cigna Network)
In-Network ONLY Plans
Deductible (Individual / Family)
$2,000 / $4,000
$1,000 / $2,000
None
Co-Insurance
100%
90%
100%
Out of Pocket Maximum (Individual / Family)
$5,550 / $11,100
$4,000 / $8,000
$2,500 / $5,000
Office Visit: Primary Care/Specialist
Deductible, $30 / $50 Deductible, $40 / $70
$30 / $50
$200 Copay, After Deductible $50 Copay, After Deductible
Emergency Room
$250 Copay
$100 Copay
Urgent Care
$75 Copay
$50 Copay
Lab: Deductible X-Ray: 10% After Deductible You pay 10% After Deductible You pay 10% After Deductible
Lab/X-Ray
Deductible
No Charge
$300 Copay, After Deductible $250 Copay, After Deductible
Inpatient Hospital
$500 Copay
Outpatient Hospital
$250 Copay
Included in Medical Deductible
$100 / $200 (Individual / Family)
Rx Deductible
None
Rx Copays
Retail (30 daysupply) Mail Order (90 daysupply)
$10 / $35 / $70 After Deductible $20 / $70 / $140 After Deductible
$15* / $35 / $75 After Deductible $38* / $88 / $150 After Deductible
$15 / $30 / $50
$38 / $75 / $125
10
PRIVATE PREP BENEFITS GUIDE
MEDICAL PLAN I
10
Made with FlippingBook - Online catalogs