NETWORK:
MEDICAL COVERAGE
Insurance Carrier:
Angle Health Medical Insurance: Cigna PPO Network
Medical Plan:
$3,000 Copay Plan
$5,000 Copay Plan
In-Network: Primary Care Visits
$20 Copay
$25 Copay
Specialist Care Visits
$50 Copay
$75 Copay
Urgent Care
$75 Copay
$85 Copay
Emergency Room Care
Deductible; then $250 Copay
Deductible; then $300 Copay
Preventative Visit Copay
$0
$0
Diagnostic Testing (X-Ray / Blood Work)
Deductible; then 20% Coinsurance
Deductible; then 20% Coinsurance
Advanced Imaging
Deductible; then 20% Coinsurance
Deductible; then 20% Coinsurance
Plan Coinsurance
80%
80%
Employee Deductible
$3,000
$5,000
Family Deductible
$6,000
$10,000
Employee Out-of-Pocket Max
$5,000 (includes deductible)
$7,000 (includes deductible)
Family Out-of-Pocket Max
$10,000 (includes deductible)
$14,000 (includes deductible)
Inpatient Hospital
Deductible; then $250 Copay
Deductible; then $300 Copay
Outpatient Hospital or Facility
Deductible; then 20% Coinsurance
Deductible; then 20% Coinsurance
Out-of-Network Plan Coinsurance
50%
50%
Employee Deductible
$6,000
$10,000 $20,000 $14,000 $28,000
Family Deductible
$12,000 $10,000 $20,000
Employee Out-of-Pocket Max
Family Out-of-Pocket Max
Prescription Drugs 30-day supply Tier 1 - Generic
$15 Copay $50 Copay $75 Copay
$20 Copay $60 Copay $85 Copay
Tier 2 - Preferred
Tier 3 - Non-Preferred
Tier 4 - Specialty
Deductible; then 20% Coinsurance
Deductible; then 20% Coinsurance
Employee Weekly Deduction Employee Only
$36.64 $206.88 $185.60 $341.67
$33.94 $191.62 $171.91 $316.46
Employee + Spouse Employee + Child(ren)
Family
6 | Terry Miller Service Company 2024 Benefits Guide
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