Medical
Medical coverage offers healthcare protection for you and your family. You may visit any medical provider you choose, but in-network providers offer the highest level of benefits and lower out-of-pocket costs. Network providers charge members reduced, contracted fees instead of their typical fees. Providers outside the plan’s network set their own rates, so you may be responsible for the difference if a provider’s fees are above the Reasonable and Customary (R&C) limits.
Preventive Care – like physical exams, flu shots, and screenings – is always covered 100% when you use in-network providers. The key difference between the plans is the amount of money you’ll pay each pay period and when you need care.
Each plan has different:
- Annual deductible amounts – the amount you pay each year for eligible in-network and out-of-network charges before the plan begins to pay.
- Out-of-pocket maximums – the most you will pay each year for eligible network services and/or prescriptions. After you reach your out-of-pocket maximum, the plan picks up the full cost of covered medical care for the remainder of the year.
- Copays – A copay is a fixed amount you pay for a health care service. Copays do not count toward your deductible but do count toward your annual out-of-pocket maximum.
- Coinsurance – Once you’ve met your deductible, you and the plan share the cost of care, which is called coinsurance. For example, you pay 20% for services and the plan will pay 80% of the cost until you have reached your out-of-pocket maximum.
Cigna HDHP Base Plan
Plan Information
Plan Name: Cigna $3,300 HDHP Base Plan
Policy Number: 655868
Effective Date: 01/01/2025
Network: Open Access Plus
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$3,300/$6,000
Out-of-Pocket Max (Individual/Family)
$4,000/$8,000
Preventive Care
$0
Primary Care Visit
$0, after deductible
Specialist Visit
$0, after deductible
Urgent Care
$0, after deductible
Emergency Room
$0, after deductible
Retail Rx (Up to 30-Day Supply)
Tier 1
$10 copay after the deducible
Tier 2
$35 copay after the deducible
Tier 3
$70 copay after the deducible
Tier 4
Specialty medications must be filled through home delivery; otherwise you pay the entire cost of the prescription upon your first fill. Some exceptions may apply.
Retail Rx (Up to 90-Day Supply)
Tier 1
$25 copay after the deducible
Tier 2
$88 copay after the deducible
Tier 3
$175 copay after the deducible
Tier 4
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Tier 1
$25 copay after the deducible
Tier 2
$88 copay after the deducible
Tier 3
$175 copay after the deducible
Tier 4
Not covered
Out-of-Network
Deductible (Individual/Family)
$9,000/$18,000
Out-of-Pocket Max (Individual/Family)
$12,000/$24,000
Preventive Care
50% coinsurance after deductible
Primary Care Visit
50% coinsurance after deductible
Specialist Visit
50% coinsurance after deductible
Urgent Care
50% coinsurance after deductible
Emergency Room
$0
Retail Rx (Up to 30-Day Supply)
Tier 1
Not covered
Tier 2
Not covered
Tier 3
Not covered
Tier 4
Not covered
Retail Rx (Up to 90-Day Supply)
Tier 1
Not covered
Tier 2
Not covered
Tier 3
Not covered
Tier 4
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Tier 1
Not covered
Tier 2
Not covered
Tier 3
Not covered
Tier 4
Not covered
Plan Documents
Contact Information
Cigna PPO Buy-Up Plan
Plan Information
Plan Name: Cigna $2,000 PPO Copay Buy-Up Plan
Policy Number: 655868
Effective Date: 01/01/2025
Network: Open Access Plus
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$2,000/$4,000
Out-of-Pocket Max (Individual/Family)
$4,000/$8,000
Preventive Care
$0
Primary Care Visit
$25 copay after the deducible
Specialist Visit
$50 copay after the deducible
Urgent Care
$75 copay after the deducible
Emergency Room
$250 copay, and 80% coinsurance after deductible
Retail Rx (Up to 30-Day Supply)
Tier 1
$10 copay after the deducible
Tier 2
$35 copay after the deducible
Tier 3
$70 copay after the deducible
Tier 4
Specialty medications must be filled through home delivery; otherwise you pay the entire cost of the prescription upon your first fill. Some exceptions may apply.
Retail Rx (Up to 90-Day Supply)
Tier 1
$25 copay after the deducible
Tier 2
$88 copay after the deducible
Tier 3
$175 copay after the deducible
Tier 4
N/A
Mail-Order Rx (Up to 90-Day Supply)
Tier 1
$25 copay after the deducible
Tier 2
$88 copay after the deducible
Tier 3
$175 copay after the deducible
Tier 4
N/A
Out-of-Network
Deductible (Individual/Family)
$4,000/$8,000
Out-of-Pocket Max (Individual/Family)
$8,000/$16,000
Preventive Care
Not covered
Primary Care Visit
50% coinsurance after deductible
Specialist Visit
50% coinsurance after deductible
Urgent Care
50% coinsurance after deductible
Emergency Room
$250 copay, and 80% coinsurance after deductible
Retail Rx (Up to 30-Day Supply)
Tier 1
Not covered
Tier 2
Not covered
Tier 3
Not covered
Tier 4
Not covered
Retail Rx (Up to 90-Day Supply)
Tier 1
Not covered
Tier 2
Not covered
Tier 3
Not covered
Tier 4
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Tier 1
Not covered
Tier 2
Not covered
Tier 3
Not covered
Tier 4
Not covered