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Cigna Medical Benefits Summary 2015
PROVIDERPLAN NAME PLAN TYPENETWORK SELECTION OPEN ACCESS PLUS AREAS AVAILABLE
NATIONAL
Calendar Year Deductible (Individual / Family)Coinsurance (Carrier / Employee)Calendar Year Out Of Pocket Maximum (Individual / Family) Out Of Pocket Maximum Includes DeductibleLifetime Maximum
Preventive Care Routine ExamsPrimary Care Office VisitSpecialist Office Visit
Routine Preventive Care Exams and ScreeningsDiagnostic LaboratoryDiagnostic X-RayDiagnostic X-Ray for Complex Imaging Services
Emergency Room VisitUrgent Care VisitAmbulance
Inpatient HospitalizationOutpatient Surgery
MENTAL HEALTH/SUBSTANCE ABUSE SERVICESInpatientOutpatient
Rx (generic/formulary brand-name/non-formulary brand-name) Specialty DrugsMail Order (90 day supply)Routine Eye Exam (Children) Skilled Nursing Facility
Calendar Year Deductible (Individual / Family)Coinsurance (Carrier / Employee)Calendar Year Out Of Pocket Maximum (Individual / Family) Lifetime MaximumPhysician Office Visit Inpatient Hospitalization Outpatient Surgery Diagnostic ServicesMental Health/Substance AbuseEmergency Room Visit
NATIONALEmployeeEmployee + Child(ren)Employee + SpouseEmployee + Family
$617$1,006$1,219$1,289
$571$915
$1,127$1,197
$531$833
$1,046$1,110
$1,098$1,311$1,380
OAP PPO 1500OAP PPO 1000$663
MONTHLY PREMIUMS (2015)OAP PPO 500OAP PPO $0
Covered 100%20% After Deductible20% After Deductible20% After Deductible
Covered 100%20% After Deductible20% After Deductible20% After Deductible
$3,000 / $6,00060% / 40%
$6,000 / $12,000Combined with In-Network
40% After Deductible40% After Deductible40% After Deductible40% After Deductible40% After DeductibleSame as In-Network
$3,000 / $6,00060% / 40%
$6,000 / $12,000Combined with In-Network
40% After Deductible40% After Deductible40% After Deductible40% After Deductible40% After DeductibleSame as In-Network
20% After Deductible20% After Deductible
20% After Deductible20% After Deductible
$10 / $30 / $60$100
$25 / $75 / $150Covered 100%
20% After Deductible
$10 / $30 / $60$100
$25 / $75 / $150Covered 100%
20% After Deductible
PHYSICIAN SERVICES
EMERGENCY MEDICAL CARE$200 Copay$60 Copay
20% After Deductible
$200 Copay$60 Copay
Covered 100%
Covered 100%$25 Copay$45 Copay
Covered 100%$25 Copay$45 Copay
Cigna$1500 Plan Traditional PPO
YesNational
Cigna$1000 Plan Traditional PPO
YesNational
$200 Copay$60 Copay
20% After Deductible
$200 Copay$60 Copay
20% After Deductible
$1,500 / $3,00080% / 20%
$3,000 / $6,000Yes
Unlimited
$1,000 / $2,00080% / 20%
$2,500 / $5,000Yes
Unlimited
Cigna$500 Plan Traditional PPO
YesNational
Cigna$0 Plan Traditional PPO
YesNational
IN-NETWORKDEDUCTIBLE & MAXIMUMS
NON NETWORK
$3,000 / $6,00060% / 40%
$6,000 / $12,000Combined with In-Network
40% After Deductible40% After Deductible40% After Deductible40% After Deductible40% After DeductibleSame as In-Network
$3,000 / $6,00060% / 40%
$6,000 / $12,000Combined with In-Network
40% After Deductible40% After Deductible40% After Deductible40% After Deductible40% After DeductibleSame as In-Network
HOSPITAL CARE
20% After Deductible20% After Deductible
Covered 100%Covered 100%
20% After Deductible20% After Deductible
Covered 100%Covered 100%
OTHER BENEFITS
20% After Deductible20% After Deductible
20% After Deductible20% After Deductible
OAP PPO 1500OAP PPO 1000
$10 / $30 / $60$100
$25 / $75 / $150Covered 100%
20% After Deductible
$10 / $30 / $60$100
$25 / $75 / $150Covered 100%
20% After Deductible
OAP PPO 500OAP PPO $0
$500 / $1,00080% / 20%
$2,000 / $4,000Yes
Unlimited
$0 / $080% / 20%
$1,500 / $3,000N/A Unlimited
Covered 100%$25 Copay$45 Copay
Covered 100%$25 Copay$45 Copay
DIAGNOSTIC SERVICES
Covered 100%20% After Deductible20% After Deductible20% After Deductible
Covered 100%Covered 100% Covered 100% Covered 100%
Cigna Medical Benefits Summary 2015
PROVIDERPLAN NAME PLAN TYPENETWORK SELECTION OPEN ACCESS PLUS AREAS AVAILABLE
NATIONAL
Calendar Year Deductible (Individual / Family)Coinsurance (Carrier / Employee)Calendar Year Out Of Pocket Maximum (Individual / Family) Out Of Pocket Maximum Includes DeductibleLifetime Maximum
Preventive Care Routine ExamsPrimary Care Office VisitSpecialist Office Visit
Routine Preventive Care Exams and ScreeningsDiagnostic LaboratoryDiagnostic X-RayDiagnostic X-Ray for Complex Imaging Services
Emergency Room VisitUrgent Care VisitAmbulance
Inpatient HospitalizationOutpatient Surgery
MENTAL HEALTH/SUBSTANCE ABUSE InpatientOutpatient
Rx (generic/formulary brand-name/non-formulary brand-name) Specialty DrugsMail Order (90 day supply)Routine Eye Exam (Children) Skilled Nursing Facility
Calendar Year Deductible (Individual / Family)Coinsurance (Carrier / Employee)Calendar Year Out Of Pocket Maximum (Individual / Family) Lifetime MaximumPhysician Office Visit Inpatient Hospitalization Outpatient Surgery Diagnostic ServicesMental Health/Substance AbuseEmergency Room Visit
NATIONALEmployeeEmployee + Child(ren)Employee + SpouseEmployee + Family
PHYSICIAN SERVICES
EMERGENCY MEDICAL CARE
IN-NETWORKDEDUCTIBLE & MAXIMUMS
NON NETWORK
HOSPITAL CARE
OTHER BENEFITS
DIAGNOSTIC SERVICES
$304$598$648$832
$490$746$959
$1,023
$414$568$781$845
$374$659$715$944
OAP PPO 2000
Covered 100%20% After Deductible20% After Deductible20% After Deductible
$6,000 / $12,00060% / 40%
$12,000 / $24,000Combined with In-Network
40% After Deductible40% After Deductible40% After Deductible40% After Deductible40% After DeductibleSame as In-Network
$500 Copay +20% After Deductible20% After Deductible
$10 / $40 / $7025%/max $300 per script
$25 / $100 / $175Covered 100%
20% After Deductible
Covered 100%$40 Copay$60 Copay
OAP PPO 2000
$300 Copay$60 Copay
20% After Deductible
$2,000 / $4,00080% /20%
$5,000 / $10,000Yes
Unlimited
$500 Copay +20% After Deductible20% After Deductible
$500 Copay +20% After Deductible20% After Deductible
$500 Copay +20% After Deductible20% After Deductible
Covered 100%30% After Deductible30% After Deductible30% After Deductible
Cigna$3000 Plan Traditional PPO
YesNational
OAP PPO 3000
$3,000 / $6,00080% /20%
$6,000 / $12,000Yes
Unlimited
Covered 100%$40 Copay$60 Copay
Covered 100%20% After Deductible20% After Deductible20% After Deductible
$10 / $40 / $7025%/max $300 per script
$25 / $100 / $175Covered 100%
20% After Deductible
$6,000 / $12,00060% / 40%
$12,000 / $24,000Combined with In-Network
40% After Deductible40% After Deductible40% After Deductible40% After Deductible40% After DeductibleSame as In-Network
OAP PPO 3000
$300 Copay$60 Copay
20% After Deductible
OAP PPO Value
$15 / $35 / $9025%/max $300 per script
$37.50 / $125 / $225Covered 100%
30% After Deductible
$10,000 / $20,00050% / 50%
$20,000 / $40,000Combined with In-Network
50% After Deductible50% After Deductible50% After Deductible50% After Deductible50% After DeductibleSame as In-Network
OAP PPO 5000
100% After Deductible100% After Deductible
100% After Deductible100% After Deductible
100% After Deductible100% After Deductible100% After Deductible
Covered 100%100% After Deductible
$12,700 / $25,40050% / 50%
$25,400 / $50,800Combined with In-Network
50% After Deductible50% After Deductible50% After Deductible50% After Deductible50% After DeductibleSame as In-Network
$400 Copay$75 Copay
30% After Deductible
Cigna$2000 Plan Traditional PPO
YesNational
OAP PPO Value
100% After Deductible100% After Deductible100% After Deductible
CignaValue Plan Health Savings PPO
YesNational
$6,350 / $12,700$100% / 0%
$6,350 / $12,700Yes
Unlimited
Covered 100%100% After Deductible100% After Deductible
Covered 100%100% After Deductible100% After Deductible100% After Deductible
$300 Copay +30% After Deductible
$150 Copay +30% After Deductible
$300 Copay +30% After Deductible30% After Deductible
Cigna$5000 Plan Traditional PPO
YesNational
OAP PPO 5000
$5,000 / $10,00070% /30%
$6,350 / $12,700Yes
Unlimited
Covered 100%$50 Copay$75 Copay
