Tacodeli
Medical Benefits for 2025
Summary of Coverage
$5,000 Deductible HDHP Plan*
$2,000 Deductible Copay Plan (PPOHI)
$4,000 Deductible Copay Plan (PPOLO)
Network
In-Network
In-Network
In-Network
Annual Deductible Individual | Family Out-of-Pocket Max Individual | Family
$2,000 | $6,000
$4,000 | $8,000
$5,000 | $10,000
$5,000 | $14,700
$5,600 | $10,200
$5,000 | $10,000
Primary Care Specialty Care
$30 copay $60 copay
$40 copay $40 copay
0% after deductible
Preventive Care
No Charge
No Charge
No Charge
Diagnostic Lab and X-ray
No Charge
No Charge
0% after deductible
Complex Radiology
20% after deductible
30% after deductible
0% after deductible
$65 copay plus 30% after deductible
Urgent Care
$75 copay
0% after deductible
20% after $500 copay
$100 copay
Emergency Room
0% after deductible
Hospital Inpatient & Outpatient
20% after deductible
30% after deductible
0% after deductible
Retail (30 day) / Mail Order (90 day)
Retail (30 day) / Mail Order (90 day)
Retail (30 day) / Mail Order (90 day)
Prescriptions
$10 / $30 Copay
$20 / $60 Copay
Generic Drug
$50 / $150 Copay
$40 / $120 Copay
Preferred Brand
0% after deductible
$100 / $300 Copay
$60 / $180 Copay
Non-Preferred
$150 Copay / NA
$80 Copay / NA
Specialty Drug**
*Enrollment in the HDHP Plan makes you eligible to open a Health Savings Account (HSA). **Specialty Drugs are available for 30-day supply ONLY
Go to hcpdirectory.cigna.com to find in-network providers in your area.
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This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2025 Employee Benefit Guide
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