Benefit Summary

Information on the Benefit Summary for the Retiree Medical Plan - Cigna OAPIN option

2021 Benefit Summary

In-Network Benefits How this Plan Works
Preventive Services
Preventive Care Office Visit No charge
Routine Physicals & Immunizations No charge
Well Woman Care (including Pap Smear Test) No charge
Mammograms No charge
Well Baby Care (including Immunizations) No charge
Prostate Cancer Screening No charge
Physician Services
Telemedicine Consultation, using Cigna designated telemedicine providers $25 copay
Primary Care Physician Office Visit $25 copay
Initial Vision and Hearing Screening in PCP Office $25 copay
Specialty Care Physician Office Visit $40 copay  
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 including Rehabilitation Hospitals and
Sub-Acute Facilities
 
Home Health Care
Home Health Care Services 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 $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
Office Visit (Tests) $25 PCP or $40 Specialist copay
Surgical Treatment: Limited to Sterilization Procedures for Vasectomy/Tubal Ligation (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
Durable Medical Equipment
Contract Year Maximum: Unlimited 90% coverage, up to the out-of-pocket maximum
External Prosthetic Appliances 90% coverage, up to the out-of-pocket 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.
 Retail Prescription Drugs/30 day supply
 Generic 20% coinsurance per prescription order or refill. The maximum copay is $105 per prescription.
 Preferred Brand 30% coinsurance per prescription order or refill. The maximum copay is $125 per prescription.
 Non-Preferred Brand

45% coinsurance per prescription order or refill. The maximum copay is $135 per prescription.

 Participating Retail, or Cigna Home Delivery Prescription Drugs/90 day supply
 Generic 20% coinsurance per prescription order or refill. The maximum copay is $155 per prescription.
 Preferred Brand 30% coinsurance per prescription order or refill. The maximum copay is $175 per prescription.

Non-Preferred Brand

45% coinsurance per prescription order or refill. The maximum copay is $200 per prescription.
Mental Health and Substance Abuse Benefits
Telemedicine Behavioral Health Consultation using Cigna designated telemedicine provider $25 copay
Individual, Family or Group Therapy Office Visit  $40 copay 
Inpatient Treatment – includes Hospital, Residential Treatment Facilities, and Partial Hospitalization  90% coverage, up to the out-of-pocket maximum 
Intensive Outpatient Treatment   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%.