Company Name • 2024-2025 Benefits Guide
MEDICAL CIGNA
www.mycigna.com 800.555.1234
Your medical benefits are provided by Cigna and provides coverage for both in-network and out-of- network providers. You will always have stronger benefits when visiting in-network providers.
Medical
$5,000 HSA Plan
$2,500 HSA Plan
$1,000 PPO Plan
In-network
In-network
In-network
Annual deductible (Individual/Family)
$5,000/$10,000
$2,500/$5,000
$1,000/$2,000
Out-of-pocket maximum (Individual/Family)*
$ 6,000/$12,000
$5,000/$6,000
$4,000/$8,000
Preventive care
100%
100%
100%
Primary physician office visit
30% coinsurance*
20% coinsurance*
$25 copay
Specialist office visit
30% coinsurance*
20% coinsurance*
$30 copay
Inpatient hospital services
30% coinsurance*
20% coinsurance*
10% coinsurance*
Outpatient hospital services (lab, x-ray, diagnostic)
30% coinsurance*
20% coinsurance*
10% coinsurance*
Advanced diagnostics
30% coinsurance*
20% coinsurance*
10% coinsurance*
Urgent care
30% coinsurance*
20% coinsurance*
$50 copay
$150 copay + 10% coinsurance*
Emergency room care
30% coinsurance*
20% coinsurance*
Prescription drugs Retail (30-day supply)
Generic
$15 copay*
$15 copay*
$15 copay
Brand preferred
$35 copay*
$25 copay*
$25 copay
Brand non-preferred
$60 copay*
$40 copay*
$40 copay
Mail order (90-day supply)
Generic
$30 copay*
$30 copay*
$30 copay
Brand preferred
$70 copay*
$50 copay*
$50 copay
Brand non-preferred
$120 copay*
$80 copay*
$80 copay
This is a summary of coverage; please refer to your summary plan description for the full scope of coverage. In-network services are based on negotiated charges; Out-of-network services are based on a percentage of Medicare charges. * After deductible is satisfied.
5
Made with FlippingBook - Online Brochure Maker