Benefits Summary

Preventive Services

Preventive Care Office Visit

No charge

Routine Physicals & Immunizations

No charge

Well Woman Care (including Pap Test)

No charge

Mammograms

No charge

Well Baby Care (including Immunizations)

No charge

Preventive Screenings (including Basic Lab Tests, Mammography, Colorectal/Prostate Cancer)

No charge

Physician Services

Telemedicine Consultation, using Cigna designated telemedicine providers

$25 copay

Primary Care Physician Office Visit

$25 co-pay

Hearing Exam (Adults over age 21)

$25 co-pay

Specialty Care Physician Office Visit

$40 co-pay

Surgery Performed in the Physician's Office

No charge after the $25 PCP or $40 Specialist copay

Allergy Treatment/Injections

No charge after either the office visit copay or the actual charge, whichever is less

Inpatient Hospital - Facility Services

Semi Private Room and Board

90% coverage up to the out-of-pocket maximum

Private Room

90% of the Hospital's negotiated rate for a semi-private room, up to the out-of-pocket maximum, then 100% of the Hospital’s negotiated rate for semi-private room

Special Care Units (ICU/CCU)

90% coverage, up to the out-of-pocket maximum

Operating Room, Recovery Room, Oxygen Anesthesia and Respiratory/Inhalation Therapy

90% coverage, up to the out-of-pocket maximum

Inpatient Professional Services

Anesthesiologists

90% coverage, up to the out-of-pocket maximum

Radiologists, Pathologists

90% coverage, up to the out-of-pocket maximum

Surgeon

90% coverage, up to the out-of-pocket maximum

Assistant Surgeon or Co-Surgeon

90% coverage, up to the out-of-pocket maximum

Physician Visit

90% coverage, up to the out-of-pocket maximum

Nursing Care

90% coverage, up to the out-of-pocket maximum

Mastectomy and Breast Reconstruction

90% coverage, up to the out-of-pocket maximum

Diagnostic and Therapeutic Laboratory and X-ray

90% coverage, up to the out-of-pocket maximum

Hemodialysis

90% coverage, up to the out-of-pocket maximum

Radiation Therapy and Chemotherapy

90% coverage, up to the out-of-pocket maximum

Organ Transplant Services

90% coverage, up to the out-of-pocket maximum

Outpatient Facility Services

Operating Room, Recovery Room, Procedure Room, and Treatment

90% coverage, up to the out-of-pocket maximum

Outpatient Professional Services

Anesthesiologists and Respiratory/Inhalation Therapy

90% coverage, up to the out-of-pocket maximum

Radiologists, Pathologists

90% coverage, up to the out-of-pocket maximum

Surgeon

90% coverage, up to the out-of-pocket maximum

Assistant Surgeon or Co-Surgeon

90% coverage, up to the out-of-pocket maximum

Physician Visit/Charges for Outpatient Surgery

90% coverage, up to the out-of-pocket maximum

Hemodialysis

90% coverage, up to the out-of-pocket maximum

Mastectomy and Breast Reconstruction

90% coverage, up to the out-of-pocket maximum

Diagnostic and Therapeutic Laboratory and X-ray

90% coverage, up to the out-of-pocket maximum

Radiation Therapy and Chemotherapy

90% coverage, up to the out-of-pocket maximum

Emergency and Urgent Care Services

Telemedicine Consultation, using Cigna designated telemedicine providers

$25 copay

Urgent Care Facility

$60 copay

Free-Standing ER or Outpatient Facility

$150 copay

Hospital Emergency Room

$150 copay*, *Waived if admitted

Ambulance

90% coverage, up to the out-of-pocket maximum

Independent Lab Services

Physician's Office

No Charge after office visit copay

Lab Facility

90% coverage, up to the out-of-pocket maximum

Hospital Outpatient

90% coverage, up to the out-of-pocket maximum

Skilled Nursing

Facility Services

90% coverage, up to the out-of-pocket maximum

Skilled Nursing Room and Board

90% coverage, up to the out-of-pocket maximum

Contract Year Maximum: 60 Days Also including Rehabilitation Hospitals and
Sub-Acute Facilities

Home Health Care

Contract Year Maximum: Unlimited

90% coverage, up to the out-of-pocket maximum

Hospice

Inpatient

90% coverage, up to the out-of-pocket maximum

Outpatient

90% coverage, up to the out-of-pocket maximum

Rehabilitative Therapy (including Speech, Occupational, Physical, Chiropractic, Pulmonary, Cardiac and Cognitive Therapy)

Inpatient

90% coverage, up to the out-of-pocket maximum

Maximum of 60 visits per contract year for any combination of Therapies (unlimited for covered mental health conditions including autism spectrum disorder and other developmental delays)

$40 copay

Maternity

Initial Visit to Confirm Pregnancy

$25 PCP or $40 Specialist copay

Subsequent Visits (Pre-Natal, Post-Natal, Physician’s Delivery Charges subject to global maternity fee)

90% coverage, up to the out-of-pocket maximum

Office Visits in addition to the global maternity fee when performed by an OB/GYN or Specialist

$25 PCP or $40 Specialist copay

Delivery (Inpatient Hospital, Birthing Center)

90% coverage, up to the out-of-pocket maximum

Family Planning

Preventive Family Planning Services (office visits, lab and radiology tests, counselling, contraceptive devices, tubal ligation; excludes reversals)

No charge

Office Visit

$25 PCP or $40 Specialist copay

Surgical Treatment:(includes Vasectomy; excludes Reversals):

90% coverage, up to the out-of-pocket maximum

Inpatient Facility

90% coverage, up to the out-of-pocket maximum

Outpatient Facility

90% coverage, up to the out-of-pocket maximum

Physician's Services

90% coverage, up to the out-of-pocket maximum

Fertility Services

Office Visit

$25 PCP or $40 Specialist copay

Surgical Treatment authorized by Progyny for in-network benefits

90% coverage, up to the out-of-pocket maximum

Inpatient Facility authorized by Progyny for in-network benefits

90% coverage, up to the out-of-pocket maximum

Outpatient Facility authorized by Progyny for in-network benefits

90% coverage, up to the out-of-pocket maximum

Physician's Services authorized by Progyny for in-network benefits

90% coverage, up to the out-of-pocket maximum

Lifetime Maximum: Surgical treatment limited to 2 “smart cycles” as defined and authorized by Progyny (3 cycles if required for first pregnancy)

Durable Medical Equipment

Contract Year Maximum: Unlimited

90% coverage, up to the out-of-pocket maximum

External Prosthetic Appliances

$200 deductible, then 100% up to a $1,000 per Contract Year maximum

Diabetes Services

Diabetes Management Medical Equipment - including blood glucose monitors, monitors designed to be used by blind individuals; insulin pumps and associated appurtenances; insulin infusion devices; and podiatric appliances for the prevention of complications associated with diabetes.

90% coverage, up to the out-of-pocket maximum

Diabetes Supplies - including test strips for blood glucose monitors, visual reading and urine test strips, lancets and lancet devices, insulin and insulin analogs, injection aids, syringes, prescriptive and non-prescriptive oral agents for controlling blood sugar levels, and glucagon emergency kits.

Same as Prescription Drug Copayment

Pharmacy Benefits

The designation of a prescription drug as Generic, Preferred Brand or Non-Preferred Brand is per generally accepted industry sources and adopted by Cigna.

Preventive Care Prescription Drugs – Including contraception and other medications as provided for by applicable law

No charge

Retail Prescription Drugs/30 day supply -
No coverage for Injectable Infertility Drugs
Generic

Preferred Brand

Non-Preferred Brand

20% co-insurance per prescription order
or refill. The maximum co-pay is $105 per prescription.
30% co-insurance per prescription order
or refill. The maximum co-pay is $125 per prescription.
45% co-insurance per prescription order
or refill.
The maximum copay is $135 per prescription.

Home DeliveryDrugs/90 day supply - No coverage for Injectable Infertility Drugs
Generic

Preferred Brand

Non-Preferred Brand

20% coinsurance per prescription order
or refill. The maximum copay is $155 per prescription.
30% co-insurance per prescription order
or refill. The maximum co-pay is $175 per prescription.
45% coinsurance per prescription order
or refill.
The maximum copay is $200 per prescription

Mental Health and Substance Use Disorder Benefits

Telemedicine Behavioral Health Consultation using Cigna designated telemedicine provider

$25 copay

Individual, Family or Group Therapy Office Visit

$25 copay

Inpatient Treatment – includes Hospital, Residential Treatment Facilities, and Partial Hospitalization

90% coverage, up to the out-of-pocket maximum

Intensive Outpatient Treatment – includes Applied Behavior Analysis (ABA) for Autism Spectrum Disorder

90% coverage, up to the out-of-pocket maximum

Home Health Services – includes ABA for Autism Spectrum Disorder

90% coverage, up to the out-of-pocket maximum

Annual Out of Pocket Maximum

Individual Out of Pocket Maximum

$3,000

Family Out of Pocket Maximum

$6,000

If an employee and one or more eligible family members are covered under this option, after one covered family member meets the individual out-of-pocket maximum, benefits for that individual are payable at 100% by the Plan. Once the family meets the family out-of-pocket maximum, benefits for all covered family members are payable at 100%.