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Cigna - Enriched Plan (OAP $1000/100%)
Benefit Plan
In-Network
(You Pay)
Out-of-Network
(You Pay)
Deductible
$1,000 / Single
$2,000 / Family
$3,000 / Single
$6,000 / Family
Coinsurance
0%
30%
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 30%
Preventive Care
0%
Deductible, then you pay 30%
Inpatient Hospital & Outpatient Surgery
Deductible, then you pay 0%
Deductible, then you pay 30%
Diagnostic Lab, X-Ray and Other Tests
0%
Deductible, then you pay 30%
Major Diagnostics
Deductible, then you pay 0%
Deductible, then you pay 30%
Emergency Room
$300 Copay
Urgent Care Center
$100 Copay
Deductible, then you pay 30%
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
EMPLOYEE COST
Type of Coverage
Monthly
Cost
Employee Only
$155.83
Employee & Spouse
$311.65
Employee & Child(ren)
$272.70
Employee & Family
$428.52
By registering on
www.mycigna.comyou 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
■ Change your mailing preferences
ACA requirement - All copays are applied
to the out-of-pocket maximum, including
Prescription Drug copays.