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

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

No charge

Physician Services

Telemedicine Consultation, using Cigna designated telemedicine providers

MDLIVE PCP - $25 copay

MDLIVE Behavioral - $25 copay

MDLIVE Specialist - $45 copay

MDLIVE Wellness - No Charge

Primary Care Physician Office Visit

$25 copay

Specialty Care Physician Office Visit

$45 copay

Surgery Performed in the Physician's Office

No charge after the $25 PCP or $45 Specialist copay

Allergy Treatment/Injections

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

Hearing Aids

Cost of physician-prescribed hearing aids will be covered up to $500 every 3 years

Inpatient Hospital - FacilityServices

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

Urgent Care - $25 copay if using MDLIVE

Urgent Care Facility

$60 copay

Free-Standing ER or Outpatient Facility

$150 copay + 90% coverage

Hospital Emergency Room

$150 copay * + 90% coverage, *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 20 days per calendar year for chiropractic visits, 36 days per calendar year for cardiac visits, 60 days per calendar year for cognitive/pulmonary visits, and 60 days per calendar year for physical/occupational visits

$25 copay if visit is through PCP

$45 copay copay if visit is through specialist

Maternity

Initial Visit to Confirm Pregnancy

$25 PCP or $45 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 $45 Specialist copay

Delivery (Inpatient Hospital, Birthing Center)

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

Women’s Family Planning

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

No charge

Men’s Family Planning

Office Visit

$25 PCP or $45 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

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

Medical Pharmaceutical Drugs

Cigna Pathwell Specialty Medical Pharmaceuticals

Other Medical Pharmaceuticals

90% coverage, up to the out-of-pocket maximum at a Pathwell designated facility; otherwise not covered

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

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.

Prescription Drug Products at Retail Pharmacies/30 day supply

Generic

$15 copay per prescription order
or refill – generic formulary drugs

Preferred Brand*

30% coinsurance per prescription order or refill. The maximum copay is $125 per prescription.

Non-Preferred Brand*

50% coinsurance per prescription order or refill. The maximum copay is $200 per prescription.

Prescription Drug Products at Retail Designated Pharmacies or Home Delivery/90 day supply

Generic

$30 copay per prescription order
or refill – generic formulary drugs

Preferred Brand*

25% coinsurance per prescription order or refill. The maximum copay is $200 per prescription.

Non-Preferred Brand*

50% coinsurance per prescription order or refill. The maximum copay is $400 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 Primary Care: Psychologist/psychiatrist counseling/services,

90% coverage: Habilitative / rehabilitative services, up to the out-of-pocket maximum

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

(combined for medical/surgical, behavioral health/substance use disorder and prescription drug benefits)

Individual Out-of-Pocket Maximum

$3,000

Family Out-of-Pocket Maximum

$6,000

If a retiree 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%.