Medical Insurance
______ offers three medical plans through Cigna. To find participating providers go to www.cigna.com and click on “Find a Doctor,” then follow the prompts to complete the search. The provider network for all three plans is “Open Access Plus.” The chart below provides a brief overview of the medical plans. This chart is intended only to highlight the benefits available
and should not be relied upon to fully determine your coverage. If the below illustration of benefits conflicts in any way with the Summary Plan Description (SPD), the SPD shall prevail. It is recommended that you review your exact description of services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.
VALUE
ENHANCED
HDHP
IN-NETWORK: Plan Year or Calendar Year Basis Deductible (Individual / Family)
Calendar Year $--.--/ $--.-- 80% / 20% $--.-- / $--.--
Calendar Year $--.-- / $--.-- 90% / 10% $--.-- / $--.--
Calendar Year $--.-- / $--.-- 100% / 0% $--.-- / $--.--
Coinsurance
Maximum Out-of-Pocket (Individual/Family)
Maximum Out-of-Pocket Includes
Deductible, Coinsurance & Copayments
Deductible, Coinsurance & Copayments
Deductible
Lifetime Maximum PREVENTIVE CARE: Wellness
Unlimited
Unlimited
Unlimited
Immunizations Mammography/Colonoscopy COPAYMENTS: Referral Required Cigna Telehealth Connection Office Visits Consultations for Illness or Injury
Covered 100%
Covered 100%
Covered 100%
No
No
No
$25
$20
Up to $40
$25 Copayment $50 Copayment
$20 Copayment $40 Copayment
Deductible Deductible Deductible Deductible Deductible Deductible
Specialist Visits Inpatient Hospital Outpatient Surgery Emergency Room
Deductible & Coinsurance Deductible & Coinsurance
Deductible & Coinsurance Deductible & Coinsurance
$250 Copayment $75 Copayment
$250 Copayment $75 Copayment
Urgent Care
OUTPATIENT DIAGNOSTIC SERVICES: Independent/Freestanding Lab and simple x-rays
Covered 100%
Covered 100%
Deductible
PRESCRIPTIONS:
Tier 1: $10 Copay Tier 2: $35 Copay Tier 3: $60 Copay
Tier 1: $10 Copay Tier 2: $35 Copay Tier 3: $60 Copay
Covered 100% after Annual Deductible
Retail (30 day supply)
OUT-OF-NETWORK Deductible (Individual / Family)
$--.-- / $--.-- $--.-- / $--.--
$--.-- / $--.-- $--.--/ $--.-- 80% / 20% Enhanced
$--.-- / $--.-- $--.-- / $--.--
Maximum Out-of-Pocket (Individual/Family)
Coinsurance
60% / 40%
80% / 20%
Bi-weekly Payroll Deductions
Value $ --.-- $--.-- $--.-- $--.--
HDHP $ --.--
Employee Only
$ --.-- $--.-- $--.-- $--.--
Employee + Spouse Employee + Child(ren)
$--.-- $--.-- $--.--
Family
1 No one in the family is eligible for benefits until the family deductible is satisfied.
HEALTHESYSTEMS BENEFITS AT A GLANCE BENEFITS AT A GLA CE
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