Annual Deductible
Individual Individual (Embedded)/Family
$1,250 $1,250/$2,500
$2,500 $2,500/$5,000
$2,000 $4,000
$4,000 $8,000
Out-of-Pocket Maximum includes copays, deductible and coinsurance
Individual Individual (Embedded)/Family
$3,750 $3,750/$7,500 Plan pays 80% You pay 20%
$7,500 $7,500/$15,000 Plan pays 50% You pay 50%
$4,000 $7,350/$8,000 Plan pays 80% You pay 20%
$8,000 $16,000
Plan pays 50% You pay 50%
Co-insurance
No Charge
No Charge
Not Covered
Not Covered
Preventive Care
Cigna Telehealth Connection Services (MDLIVE® or Amwell®)
You pay $45-$49. After Deductible, you pay 20%
No Charge
Not Covered
Not Covered
After Deductible, you pay 50% After Deductible, you pay 50%
After Deductible, you pay 20% After Deductible, you pay 20% After Deductible, you pay 20% After Deductible, you pay 20% After Deductible, you pay 20%
After Deductible, you pay 50% After Deductible, you pay 50% After Deductible, you pay 20% After Deductible, you pay 20% After Deductible, you pay 20%
Primary Care Physician (PCP) Office Visit
$30 Copay
Specialist Office Visit
$40 Copay
Urgent Care
$50 Copay
$50 Copay
After Deductible, you pay 20%
After Deductible, you pay 20%
Emergency Room
Emergency Medical Transportation
No Charge
No Charge
Inpatient Hospitalization & Professional Services
After Deductible, you pay 20%
After Deductible, you pay 50%
After Deductible, you pay 20%
After Deductible, you pay 50%
After Deductible, you pay 20%
After Deductible, you pay 50%
After Deductible, you pay 20%
After Deductible, you pay 50%
Outpatient Facility & Professional Services
20% ($10 min, $20 max) 30% ($25 min, $50 max) 40% ($50 min, $100 max) 50% ($75 min, $150 max) 20% ($25 min, $50 max) 30% ($50 min, $100 max) 40% ($100 min, $200 max) 50% ($150 min, $300 max)
After Deductible, you pay 50% After Deductible, you pay 50% After Deductible, you pay 50% After Deductible, you pay 50%
After Deductible, you pay 20% After Deductible, you pay 20% After Deductible, you pay 20% After Deductible, you pay 20% After Deductible, you pay 20% After Deductible, you pay 20% After Deductible, you pay 20% After Deductible, you pay 20%
After Deductible, you pay 50% After Deductible, you pay 50% After Deductible, you pay 50% After Deductible, you pay 50%
Generic Medications
Preferred Brand Medications
Non-Preferred Brand Medications
Specialty Medications
Generic Medications
Not Covered
Not Covered
Preferred Brand Medications
Not Covered
Not Covered
Non-Preferred Brand Medications
Not Covered
Not Covered
Specialty Medications
Not Covered
Not Covered
Made with FlippingBook Annual report