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Cigna 90/70 PPO Plan


PLAN FEATURES

IN-NETWORK

OUT-OF-NETWORK
Coinsurance
90% 70%
Calendar Year Deductible: Individual
$300 $600
Calendar Year Deductible: Family
$600  $1,200
Maximum Annual Out-of-Pocket: Individual
$2,000 $4,000
Maximum Annual Out-of-Pocket: Family
$4,000 $8,000
OFFICE VISITS AND OUTPATIENT SERVICES    
Primary Care Provider (PCP)
$20 Copay  70% after deductible
Specialist
 $20 Copay 70% after deductible
Chiropractic
 $20 Copay  70% after deductible
          Acupuncture (20 visit calendar year maximum)  $20 Copay  70% after deductible
Urgent Care
$50 Copay (waived if admitted) then 100% after deductible
         Telehealth  $20 Copay  Not Covered
         Hearing Aid Benefit 90% after deductible 70% after deductible
PREVENTIVE CARE    
Routine preventive physical exams – including related preventive screenings and immunizations
No Charge  70% after deductible
LABORATORY AND X-RAY SERVICES    
Physician’s Office
 $20 Copay  70% after deductible
Outpatient
 90% after deductible   70% after deductible
HOSPITAL SERVICES    
Emergency Room (waived if admitted)
 $100 Copay then 100% after deductible
Hospital Inpatient
 90% after deductible  70% 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
 90% after deductible  70% after deductible
Outpatient - Physician's Office
 $20 Copay  70% after deductible
Outpatient - Facility
 90% after deductible  70% after deductible
PRESCRIPTION DRUGS    
Retail (30-day supply)
Generic
Formulary brand
Non-formulary brand
 
$15
$30
$50
 

Not Covered
Mail Order (90-day supply)
Generic
Formulary brand
Non-formulary brand
 
$30
$60
$100
 

Not Covered