| Network |
See Provider |
See Provider |
| Application |
Open Access 2000 Application |
Open Access 2000 Application |
| Brochure |
Open Access 2000 Brochure |
Open Access 2000 Brochure |
| Copay |
Primary Care Physician - $25, Specialist - $50 |
CIGNA pays 60% after deductible is fulfilled |
| Office Visit |
Primary Care Physician - $25, Specialist - $50 |
CIGNA pays 60% after deductible is fulfilled |
| Deductible |
Individual: $2,000, Family: $6,000 |
Individual: $4,000, Family: $12,000 |
| Coinsurance |
CIGNA pays 80% after deductible is fulfilled |
CIGNA pays 60% after deductible is fulfilled |
| Coinsurance Limit |
N/A |
N/A |
| Out-of-Pocket Maximum |
Individual: $2,500, Family: $5,000 |
Individual: $5,000, Family: $10,000 |
| Lifetime Maximum |
$5,000,000 in- and out-of-network combined |
$5,000,000 in- and out-of-network combined |
| Prescription Drugs |
Retail Pharmacy (per 30 day supply):- Brand Name Deductible - $100 per person, per calendar year
- Generic/Preferred Brand Name/Non-preferred Brand Name - $10/$35/$60
- Self Injectables - CIGNA pays 80% after deductible is fulfilled
Mail Order Pharmacy (per 90 day supply):- Brand Name Deductible - $100 per person, per calendar year
- Generic/Preferred Brand Name/Non-preferred Brand Name - $25/$85/$150
- Self Injectables - CIGNA pays 80% after deductible is fulfilled
|
Retail Pharmacy (per 30 day supply):- Brand Name Deductible - $100 per person, per calendar year
- Generic/Preferred Brand Name/Non-preferred Brand Name - CIGNA pays 50% after deductible is fulfilled
- Self Injectables - CIGNA pays 50% after deductible is fulfilled
Mail Order Pharmacy (per 90 day supply):- Generic/Preferred Brand Name/Non-preferred Brand Name - Not covered
- Self Injectables - Not covered
|
| Emergency Room |
Hospital Emergency Room - $150 additional deductible (waived if admitted) CIGNA pays 80% after deductible is fulfilled Ambulance - CIGNA pays 80% after deductible is fulfilled (Calendar year maximum of $5,000) Urgent Care Services - $50, deductible waived |
Hospital Emergency Room - $150 additional deductible (waived if admitted) CIGNA pays 60% after deductible is fulfilled Ambulance - CIGNA pays 60%after deductible is fulfilled (Calendar year maximum of $5,000) Urgent Care Services - CIGNA pays 60% after deductible is fulfilled |
| Adult Preventative Care |
Adult Preventive Care (age 7 and up):- Routine Physicals - Office visits $25/$50
- Immunizations, Flu shots, Labs - CIGNA pays 100% up to a maximum payment of $300 per year, per person
- Mammogram, Pap Smear, PSA and Colonoscopy - CIGNA pays 100%, deductible waived
|
Children Through Age 6:- Office Visit - CIGNA pays 60% after deductible is fulfilled
- Immunizations - CIGNA pays 60% after deductible is fulfilled
|
| Child Preventative Care |
Children Through Age 6:- Office Visit - $25 copay
- Specialist - $50 copay
- Immunizations - CIGNA pays 100%, deductible waived
|
Children Through Age 6:- Office Visit - CIGNA pays 60% after deductible is fulfilled
- Immunizations - CIGNA pays 60% after deductible is fulfilled
|
| Lab / X-Ray |
Lab, X-ray, Ultrasound, CT Scan and MRI - CIGNA pays 80% after deductible is fulfilled |
Lab, X-ray, Ultrasound, CT Scan and MRI - CIGNA pays 60% after deductible is fulfilled |
| Maternity |
Not covered |
Not covered |
| Physical Therapy |
Physical/Occupational/Speech Therapy - CIGNA pays a maximum of $30 per visit after deductible, per person, up to 24 combined visits per year Spinal Manipulation - $50 |
Physical/Occupational/Speech Therapy - CIGNA pays a maximum of $30 per visit after deductible, per person, up to 24 combined visits per year Spinal Manipulation - CIGNA pays 60% after deductible is fulfilled |
| Skilled Nursing |
Skilled Nursing - CIGNA pays 80% up to a $400 per day maximum after deductible is fulfilled (60 day maximum per year, in- and out-of-network combined |
Skilled Nursing - CIGNA pays 60% up to a $400 per day maximum after deductible is fulfilled (60 day maximum per year, in- and out-of-network combined |
| Home Health Care |
Home Health Care - CIGNA pays 80% after deductible is fulfilled |
Home Health Care - CIGNA pays 60% after deductible is fulfilled |
| Mental Health |
Inpatient - CIGNA pays 80% after deductible is fulfilled – ($2,500 maximum payment per person, per year, in- and out-of-network combined) Outpatient - CIGNA pays 80% after deductible is fulfilled (20 visit maximum per year, in- and out-of-network combined) |
Inpatient - CIGNA pays 60% after deductible is fulfilled ($2,500 maximum payment per person, per year, in- and out-of-network combined) Outpatient - CIGNA pays 60% after deductible is fulfilled (20 visit maximum per year, in- and out-of-network combined) |
| Hospital Care |
Inpatient Hospital Services - CIGNA pays 80% after deductible is fulfilled |
Inpatient Hospital Services - CIGNA pays 60% after deductible is fulfilled |
| Optional Benefits |
N/A |
N/A |