MEDICAL
Foley Products Company offers the following plans through Cigna. Please reference the Summary Plan Description for more details.
Insurance Carrier:
Cigna Medical Insurance
Medical Plan:
HSA
Gold
In-Network: Office Visit Copay - Primary Care
Deductible; then 100% Coinsurance
$25 Copay $50 Copay $60 Copay
Office Visit Copay - Specialist Care Deductible; then 100% Coinsurance
Urgent Care Copay Emergency Room Care (waived if admitted) Preventative Visit Copay
Deductible; then 100% Coinsurance
Deductible; then 100% Coinsurance
$150 Copay; then 80% Coinsurance
100% Coinsurance; No Deductible
100% Coinsurance; No Deductible
Coinsurance
100%
80%
Employee Deductible Family Deductible
$3,500 $7,000 $6,300 $12,600
$2,500 $7,500 $5,000 $10,000
Employee Out-of-Pocket Max Family Out-of-Pocket Max
Inpatient Hospital
Deductible; then 100% Coinsurance Deductible; then 100% Coinsurance
Deductible; then 80% Coinsurance $150 Copay; Deductible; then 80%
Outpatient Hospital or Facility
Out-of-Network: Coinsurance
70%
60%
Employee Deductible Family Deductible
$7,000 $14,000 $18,900 $37,800
$5,000 $15,000 $15,000 $30,000
Employee Out-of-Pocket Max Family Out-of-Pocket Max
Prescription Drugs: (30 Day Supply) Tier 1 - Generic
Deductible; then 100% Coinsurance Deductible; then 100% Coinsurance Deductible; then 100% Coinsurance Deductible; then 100% Coinsurance
$15 Copay $40 Copay $75 Copay
Tier 2 - Preferred
Tier 3 - Non-Preferred
Tier 4 - Specialty
20% Coinsurance
RATES:
Weekly $37.00 $83.00 $78.00 $127.00
Monthly $160.00 $361.33 $339.54 $550.88
Weekly $71.00 $142.00 $133.00 $216.00
Monthly $306.45 $613.48 $576.14 $937.25
Employee Only
Employee + Spouse Employee + Child(ren)
Family
6 | Foley Products Company Benefit Guide
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