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CIGNA HDHP 2600 (HSA Option)
CIGNA HDHP 2600 (plan with option for an HSA)
Employee Pays
In-Network
Out-of-Network
Deductible*
Individual
Family
$2,600
$5,200
$2,600**
$5,200**
Maximum Out of Pocket (OOP) ***
Individual
Family
Includes Deductible and Coinsurance
$5,000
$10,000*
Includes Deductible and Coinsurance
$10,000**
$20,000**
Lifetime Maximum
Unlimited
Office Visits
Primary Care Provider
Specialist
20% After Deductible
20% After Deductible
40% After Deductible
40% After Deductible
Preventive Care
Child Services (up to age 13)
Adult Service
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 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 Visits 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
20% After Deductible
20% After Deductible
40% After Deductible
40% After Deductible
Mental Health
Inpatient and Intermediate Care
Outpatient Care
20% After Deductible
20% After Deductible
40% After Deductible
40% After Deductible
Prescription Drugs**
Retail Pharmacy Drugs
Mail Order
20% After Deductible
Retail 40% After Deductible
Mail Order Not Covered
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