2016 Benefit Guide -Versa-Tags

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Cigna - Buy-Up Plan (OAP $500/80%)
Benefit Plan In-Network
(You Pay)
Out-of-Network
(You Pay)
Deductible $500 / Single
$1,000 / Family
$1,500 / Single
$3,000 / Family
Coinsurance 20% 50%
Out-of-Pocket Maximum
$6,850 / Single
$13,700 / Family
$13,700 / Single
$27,400 / Family
Physician Office Visit
$35 Primary Care
$70 Specialist
Deductible, then you pay 50%
Preventive Care 0% Deductible, then you pay 50%
Inpatient Hospital & Outpatient Surgery Deductible, then you pay 20% Deductible, then you pay 50%
Diagnostic Lab, X-Ray and Other Tests 0% Deductible, then you pay 50%
Major Diagnostics Deductible, then you pay 20% Deductible, then you pay 50%
Emergency Room $300 Copay
Urgent Care Center $100 Copay Deductible, then you pay 50%
Prescription Drug Coverage (at Participating In-Network Pharmacies)
Tier One $15 Copay
Tier Two $45 Copay
Tier Three $65 Copay
Mail Order Drug Coverage for a 90 Day Supply $35/$125/$185 Copay
By registering on you can get the tools you need to
make better health care choices. Here is a sampling of what you can do and
find on the website…
■ View your claims
■ Access claim forms
■ Print an ID card
■ Look up your benefits
■ Find a doctor
■ Locate a pharmacy, refill a prescription
■ View an online statement
■ Estimate health care costs
■ Talk to a nurse
■ Look up health topics
ACA requirement - All copays are
applied to the out-of-pocket maximum,
including Prescription Drug copays.
EMPLOYEE COST
Type of Coverage
Monthly
Cost
Employee Only $131.39
Employee & Spouse $262.78
Employee & Child(ren) $229.94
Employee & Family $361.32