MEDICAL PLANS - Coverage Chart Administered by CIGNA
Medical HDHP
Medical IN
Medical PPO
Plan Features
In-Network ONLY
In-Network ONLY
In-Network
Out-of-Network
Deductibles – What You Pay First for Some Services
Individual
$2,500
$2,000
$1,000
$3,000
Family
$5,000
$4,000
$2,000
$6,000
Out-of-Pocket Maximum – Most You Have to Pay for Eligible Services
Individual
$6,000
$4,500
$5,000
$9,500
Family
$12,000
$9,000
$10,000
$19,000
Medical Services – What You Pay
Preventative Care
No charge
No charge
No charge
30% After Deductible
Primary Care Physician (PCP) Office Visit Mental Health: Outpatient Office Visit
10% After Deductible
$25 copay
$25 copay
30% After Deductible
10% After Deductible
$40 copay
$50 copay
30% After Deductible
MDLive Virtual Care
10% After Deductible
$13 Copay
$13 Copay
30% After Deductible
Specialist Office Visit
10% After Deductible
$40 copay
$50 copay
30% After Deductible
Inpatient or Outpatient Hospital Care
10% After Deductible
20% After Deductible
Deductible
30% After Deductible
$400 copay (waived if admitted)
$400 copay (waived if admitted)
Emergency Room Visit
10% After Deductible
Urgent Care Visit
10% After Deductible
$25 copay
$25 copay
30% After Deductible
Prescription Drugs – What You Pay
Rx Deductible
Medical Ded. Applies
None
$100 Single / $200 Family
N/A
$20 copay no deductible (retail) $40 copay no deductible (home delivery) $40 copay after deductible (retail) $80 copay no deductible (home delivery) $80 copay after deductible (retail) $160 copay no deductible (home delivery)
$20 copay (retail 30 days) $50 copay (retail & home delivery 90 days) $45 copay (retail 30 days) $113 copay (retail & home delivery 90 days) $80 copay (retail 30 days) $200 copay (retail & home delivery 90 days)
$10 copay (retail 30 days) $20 copay (retail & home delivery 90 days) $50 copay (retail 30 days) $100 copay (retail & home delivery 90 days) $80 copay (retail 30 days) $160 copay (retail & home delivery 90 days)
Generic Copays (Tier 1)
Not covered
Preferred Brand Copays (Tier 2)
Not covered
Non-Preferred Brand (Tier 3)
Not covered
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