| Copay |
N/A |
N/A |
| OfficeVisit |
Office Visit -
- Primary Care Physician: Cigna pays 100%
- Specialist Physician: Cigna pays 100%
|
Office Visit -
- Primary Care Physician: Cigna pays 70%
- Specialist Physician: Cigna pays 70%
|
| Deductible true |
Individual: $3,500, Family: $7,000 (All benefits listed are subject to the deductible unless otherwise noted) |
Individual: $7,000, Family: $14,000 (All benefits listed are subject to the Deductible unless otherwise noted) |
| Coinsurance |
Cigna pays 100% of eligible charges |
Cigna pays 70% of eligible charges |
| Coinsurance Limit |
N/A |
N/A |
| Out-of-Pocket Maximum |
N/A |
N/A |
| Lifetime Maximum |
Unlimited |
Unlimited |
| Prescription Drugs |
Prescription Drugs -
- Prescription Drug Deductible: subject to integrated medical/pharmacy Deductible
- Retail Pharmacy -
- Generic: Cigna pays 100% per 30-day supply
- Brand Name: Cigna pays 100% per 30-day supply
- Non-Preferred
|
Prescription Drugs -
- Prescription Drug Deductible: Subject to integrated medical/pharmacy deductible
- Retail Pharmacy -
- Generic: Cigna pays 50%
- Brand Name: Cigna pays 50%
- Non-Preferred Brand Name: Cigna pays 50%
- Self A
|
| Emergency Room |
Emergency & Urgent Care Services -
- Hospital Emergency Room: Cigna pays 100%
- Outpatient Professional Services (including Radiology, Pathology and ER Physician): Cigna pays 100%
- Urgent Care Services: Cigna pays 100%
- Ambulance (Emerge
|
Emergency & Urgent Care Services -
- Hospital Emergency Room: Cigna pays 100%
- Outpatient Professional Services (including Radiology, Pathology and ER Physician): Cigna pays 70%
- Urgent Care Services: Cigna pays the same level as in Network
|
| Adult Preventative Care |
Preventive Care for All Ages (Routine physicals and other routine preventive services): Cigna pays 100% (Deductible waived) |
Preventive Care for All Ages (Routine physicals and other routine preventive services): Cigna pays 70% after deductible |
| Child Preventative Care |
Preventive Care for All Ages (Routine physicals and other routine preventive services): Cigna pays 100% (Deductible waived) |
Preventive Care for All Ages (Routine physicals and other routine preventive services): Cigna pays 70% after deductible |
| Lab / X-Ray |
Lab, X-ray and Ultrasound: Cigna pays 100%
CT/PET Scans and MRI: Cigna pays 100% |
Lab, X-ray and Ultrasound: Cigna pays 70%
CT/PET Scans and MRI: Cigna pays 70% |
| Maternity |
Not Covered |
Not Covered |
| Physical Therapy |
Cardiac & Pulmonary Rehabilitation (Calendar year maximum of 36 visits, combined in and out-of-network): Cigna pays 100%
Physical and Occupational Therapy: Cigna pays maximum of $40 per visit |
Cardiac & Pulmonary Rehabilitation (Calendar year maximum of 36 visits, combined in and out-of-network): Cigna pays 70%
Physical and Occupational Therapy: Cigna pays maximum of $40 per visit |
| Home Health Care |
Home Health (Calendar year maximum of 80 visits combined in and out-of-network): Cigna pays 100%
Hospice: Cigna pays 100% |
Home Health (Calendar year maximum of 80 visits combined in and out-of-network): Cigna pays 70%
Hospice: Cigna pays 70% |
| Mental Health |
Inpatient (Includes Acute, Partial & Residential Treatment): Cigna pays 100%
Outpatient (Includes Individual, Group & Intensive Outpatient): Cigna pays 100% |
Inpatient (Includes Acute, Partial & Residential Treatment): Cigna pays 70%
Outpatient (Includes Individual, Group & Intensive Outpatient): Cigna pays 70% |
| Hospital Care |
Surgery (in any setting): Cigna pays 100%
Facility Services (Inpatient Room and Board, Pharmacy, X-ray and Laboratory, Operating Room, etc.): Cigna pays 100%
Inpatient Physician Services and all in Hospital Care: Cigna pays 100%
Outpat |
Surgery (in any setting): Cigna pays 70%
Facility Services (Inpatient Room and Board, Pharmacy, X-ray and Laboratory, Operating Room, etc.): Cigna pays 70%
Inpatient Physician Services and all in Hospital Care: Cigna pays 70%
Outpatien |
