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Cigna HSA Plan


PLAN FEATURES

IN-NETWORK

OUT-OF-NETWORK
Coinsurance
90% 70%
Calendar Year Deductible: Individual
$1,700 $3,400
Calendar Year Deductible: Family
$3,400  $6,800
Maximum Annual Out-of-Pocket: Individual
$3,400 $6,800
Maximum Annual Out-of-Pocket: Family
$6,800 $13,600
OFFICE VISITS AND OUTPATIENT SERVICES    
Primary Care Provider (PCP)
 90% after deductible  70% after deductible
Specialist
 90% after deductible 70% after deductible
Chiropractic
 90% after deductible  70% after deductible
         Acupuncture (20 visit calendar year maximum)  90% after deductible 70% after deductible 
Urgent Care
90% after deductible
         Telehealth  90% after deductible  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
 90% after deductible  70% after deductible
Outpatient
 90% after deductible   70% after deductible
HOSPITAL SERVICES    
Emergency Room (waived if admitted)
90% 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
 90% after deductible  70% after deductible
Outpatient - Facility
 90% after deductible  70% after deductible
PRESCRIPTION DRUGS    
Retail (30-day supply)
Generic
Formulary brand
Non-formulary brand
 
 30% after deductible
 40% after deductible
 50% after deductible
 


Not Covered
Mail Order (90-day supply)
Generic
Formulary brand
Non-formulary brand
 
 30% after deductible
 40% after deductible
 50% after deductible
 


Not Covered