California Only Health Maintenance Organization (HMO)
Cigna HMO (Southern California Network)
Coinsurance
Cigna pays 100%
HMO health plan offers a local network of doctors and hospitals for you to choose from. ✓ In-Network PCP is required ✓ Referrals to a specialist are need except for OB/GYNs ✓ Out-of-network coverage is permitted for emergency care only, as defined by the plan.
Deductible Individual / Family
$500 / $1,000
Out-of-pocket Max Individual / Family
$3,000 / $6,000
Preventative Care
Covered at 100%
Office Visit PCP/Specialist
$20 Copay
Emergency Room $200 Copay
Waived if Admitted
Urgent Care
$25 Copay
For illustrative purposes only. Please refer to your plan documents for all plan details
Rx Copays
$10 / $25 / $45
3
Proprietary and confidential. All rights reserved.
Made with FlippingBook Ebook Creator