Rag & Bone - 2023 Benefit Guide

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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