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Cigna Premier PPO Plan


PLAN FEATURES    
 
IN-NETWORK
 
OUT-OF-NETWORK*
Coinsurance
100% 70%
Calendar Year Deductible: Individual
$150
$450
Calendar Year Deductible: Family
$450
$900
Maximum Annual Out-of-Pocket: Individual
$1,250
$2,500
Maximum Annual Out-of-Pocket: Family
$2,500
$5,000
OFFICE VISITS AND OUTPATIENT SERVICES    
Primary Care Provider (PCP)
$15 Copay
 70% after deductible
Specialist
$15 Copay
70% after deductible
Chiropractic
$15 Copay
 70% after deductible
          Acupuncture (20 visit calendar year maximum) $15 Copay
 70% after deductible
Urgent Care
$25 Copay (waived if admitted) then 100% after deductible
         Telehealth $15 Copay
 Not Covered
         Hearing Aid Benefit  100% 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
$15 Copay
 70% after deductible
Outpatient
 100% after deductible   70% after deductible
HOSPITAL SERVICES    
Emergency Room (waived if admitted)
$75 Copay then 100% after deductible
Hospital Inpatient
 100% after deductible  70% after deductible
INFERTILITY TREATMENT    
Covered Services
Infertility diagnosis not required for treatment of underlying condition, artificial insemination, and advanced infertility services including: GIFT, ZIFT and invitro fertilization.

Egg freezing & sperm preservation also covered without infertility diagnosis.
Lifetime Maximum Benefit
$25,000 advanced infertility services (injectable drugs count toward this maximum while oral infertility drugs do not)
GENDER CONFIRMATION BENEFITS    
Covered Services
Expanded coverage of medically necessary transitional related care reconstructive procedures that impact a person's gender identity including: gender confirmation surgery, mastectomy with chest reconstruction (top surgery), scrotoplasty, phalloplasty, augmentation mammoplasty, mental health and hormone replacement therapy services.
MENTAL HEALTH & SUBSTANCE ABUSE/CHEMICAL DEPENDENCY    
Inpatient
 100% after deductible  70% after deductible
Outpatient - Physician's Office
$15 Copay
 70% after deductible
Outpatient - Facility
 100% after deductible  70% after deductible
PRESCRIPTION DRUGS    
Retail (30-day supply)
Generic

Formulary brand

Non-formulary brand
 
$10

$25

$40
 


Not Covered
Mail Order (90-day supply)
Generic

Formulary brand

Non-formulary brand
 
$20

$50

$80
 


Not Covered

*You may pay more for OUT-OF-NETWORK services, including Infertility Treatment, based on the Maximum Reimbursable Charge. For more information, please review the Summary Plan Descriptions located in Workday.