Benefit Summary
Information on the Benefit Summary for the Retiree Medical Plan - Cigna OAPIN option
2022 In-Network 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 |
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 copay |
Hearing Screening (Adults over age 21) 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 - 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 |
$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 |
|
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 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 |
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%. |