Resources‎ > ‎

Cigna 80/60 PPO Plan


PLAN FEATURES

IN-NETWORK

OUT-OF-NETWORK
Coinsurance
80% 60%
Calendar Year Deductible: Individual
$1,000
$2,000
Calendar Year Deductible: Family
$2,000
$4,000
Maximum Annual Out-of-Pocket: Individual
$5,000
 $10,000
Maximum Annual Out-of-Pocket: Family
$10,000
$20,000
OFFICE VISITS AND OUTPATIENT SERVICES    
Primary Care Provider (PCP)
$30 Copay  60% after deductible
Specialist
 $30 Copay 60% after deductible
Chiropractic
 $30 Copay  60% after deductible
         Acupuncture (20 visit calendar year maximum)  $30 Copay  60% after deductible
Urgent Care
$75 Copay (waived if admitted) then 100% after deductible
         Telehealth      $30 Copay  Not Covered
         Hearing Aid Benefit  80% after deductible  60% after deductible
PREVENTIVE CARE    
Routine preventive physical exams – including related preventive screenings and immunizations
No Charge  60% after deductible
LABORATORY AND X-RAY SERVICES    
Physician’s Office
 $30 Copay  60% after deductible
Outpatient
 80% after deductible   60% after deductible
HOSPITAL SERVICES    
Emergency Room (waived if admitted)
$150 Copay then 100% after deductible
Hospital Inpatient
 80% after deductible   60% after deductible
 INFERTILITY TREATMENT    
Covered Services
Limited to coverage of diagnosis and treatment of underlying condition and artificial insemination.
Lifetime Maximum Benefit
N/A
GENDER CONFIRMATION BENEFITS    
Covered Services
Coverage of medically necessary transitional related care that impact a person's gender identity including: some gender confirmation surgery, mastectomy, mental health and hormone replacement therapy services.
MENTAL HEALTH & SUBSTANCE ABUSE/CHEMICAL DEPENDENCY    
Inpatient
 80% after deductible  60% after deductible
Outpatient - Physician's Office
 $30 Copay  60% after deductible
Outpatient - Facility
 80% after deductible  60% after deductible
PRESCRIPTION DRUGS    
Retail (30-day supply)
Generic
Formulary brand
Non-formulary brand
 
$20
$30
$50
 


Not Covered
Mail Order (90-day supply)
Generic
Formulary brand
Non-formulary brand
 
$40
$60
$100
 


Not Covered