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CIGNA HDHP 1500 (HSA Option)
CIGNA HDHP 1500 (plan with option for an HSA)
Employee Pays
In-Network
Out-of-Network
Deductible*
Individual
Family
$1,500
$3,000
$1,500**
$3,000**
Maximum Out of Pocket (OOP)***
Individual
Family
$3,000
$6,000*
$6,000**
$12,000**
Lifetime Maximum
Unlimited
Office Visits
Primary Care Provider
20% After Deductible
40% After Deductible
Preventive Care
Child Services (up to age 13)
Adults’ Services
0% (Not Subject to Deductible)
0% (Not Subject to Deductible)
40% After Deductible
Inpatient Services****
20% After Deductible
40% After Deductible
Outpatient Services****
Surgery / Therapeutic
Lab / X-rays
20% After Deductible
20% After Deductible
40% After Deductible
40% After Deductible
Emergency Care
20% After In Network Deductible
Urgent Care
20% After In Network Deductible
Ambulance
20% After In Network Deductible
Skilled Nursing Facility
(100 Days per calendar year in- and out-
of-network combined)
20% After Deductible
40% After Deductible
Home Health Care
(100 Days per calendar year)
20% After Deductible
40% After Deductible
Durable Medical Equipment
20% After Deductible
40% After Deductible
Vision
Not Covered
Not Covered
Substance Abuse Service
Inpatient
Outpatient Office/Facility
20% After Deductible
20% After Deductible
40% After Deductible
40% After Deductible
Mental Health
Inpatient
Outpatient Office/Facility
20% After Deductible
20% After Deductible
40% After Deductible
40% After Deductible
Prescription Drugs***
Tier 1 (Generic)
Tier 2 (Preferred Brand)
Tier 3 (Non-Preferred Brand)
Mail Order – Tier 1 - 3
20% After Deductible
Retail 40% After Deductible
Mail Order Not Covered
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