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Cigna Premier PPO Plan


PLAN FEATURES    
 
IN-NETWORK
 
OUT-OF-NETWORK
Coinsurance
100% 70%
Calendar Year Deductible: Individual
2018: $150
2017: $100
2018: $450
2017: $300
Calendar Year Deductible: Family
2018: $450
2017: $300
2018: $900
2017: $600
Maximum Annual Out-of-Pocket: Individual
2018: $1,250
2017: $1,000
2018: $2,500
2017: $2,000
Maximum Annual Out-of-Pocket: Family
2018: $2,500
2017: $2,000
2018: $5,000
2017: $4,000
OFFICE VISITS AND OUTPATIENT SERVICES    
Primary Care Provider (PCP)
2018: $15 Copay
2017: $10 Copay
 70% after deductible
Specialist
2018: $15 Copay
2017: $10 Copay
70% after deductible
Chiropractic
2018: $15 Copay
2017: $10 Copay
 70% after deductible
          Acupuncture (20 visit calendar year maximum) 2018: $15 Copay
2017: $10 Copay
 70% after deductible
Urgent Care
$25 Copay (waived if admitted) then 100% after deductible
         Telehealth 2018: $15 Copay
2017: $10 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
2018: $15 Copay
2017: $10 Copay
 70% after deductible
Outpatient
 100% after deductible   70% after deductible
HOSPITAL SERVICES    
Emergency Room (waived if admitted)
2018: $75 Copay then 100% after deductible
2017: $50 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
2018: $15 Copay
2017: $10 Copay
 70% after deductible
Outpatient - Facility
 100% after deductible  70% after deductible
PRESCRIPTION DRUGS    
Retail (30-day supply)
Generic

Formulary brand

Non-formulary brand
 
2018: $10
2017: $5 
2018: $25
2017: $15
2018: $40
2017: $30 
 

Not Covered
Mail Order (90-day supply)
Generic

Formulary brand

Non-formulary brand
 
 2018: $20
2017: $10
2018: $50
2017: $30
2018: $80
2017: $60
 

Not Covered