Copay Base Plan
This chart gives an overview of the medical Copay plans administered by Cigna. As a member of a Copay plan, you can use the doctors and hospitals within the Open Access Plus In (OAPIN) network, but cannot go outside the network for care. There are no out-of-network benefits, except for emergency services. Refer to the medical benefits summary from Cigna for more details.
Medical | Copay Base | |
---|---|---|
IN-NETWORK | OAPin | |
Primary Residence | Nationwide | |
Calendar Year Deductible | Embedded | |
Individual | Family | $1250 | $2500 |
Plan Coinsurance | 70% | |
Out of Pocket Max (Coinsurance, Copays & Deductible Apply To Out of Pocket) | Embedded | |
Individual | Family | $4500 | $9000 |
Physician & Emergent Care | ||
Preventive Care | No charge | |
PCP | Specialist | CCN: $10 NCCN: $20 | CCN: $35 NCCN: $50 |
PCP Required | No | |
Referral Required | No | |
Virtual Visits | $5 | |
Convenience Care (i.e. CVS Minute Clinic) | $20 | |
Urgent Care | $50 | |
Emergency Room (In or out of network) | $500 | |
Hospitalization & Outpatient Care | ||
Inpatient | 30% after deductible | |
Outpatient | 30% after deductible | |
Physician Fees | 30% after deductible | |
Independent Facility Care | ||
Labs | No charge | |
X-rays | No charge | |
Complex Diagnostic Imaging | 30% after deductible | |
Prescription Drugs | Mandatory Generic | |
Deductible | $0 | |
Tier 1 | $10 | |
Tier 2 | $35 | |
Tier 3 | $60 | |
Specialty (GH, Self Injectable, etc) | $125 | |
Mail Order - 90 day supply | 2.5 x retail copay | |
OUT-OF-NETWORK | ||
Deductible Individual | Family | No benefits except emergency services | |
Plan Coinsurance | No benefits except emergency services | |
Out of Pocket Max | No benefits except emergency services | |
Office Charges | No benefits except emergency services | |
Facility Charges | No benefits except emergency services | |
Balance Billing | No benefits except emergency services |
Copay High Plan
This chart gives an overview of the medical Copay plans administered by Cigna. As a member of a Copay plan, you can use the doctors and hospitals within the Open Access Plus In (OAPIN) network, but cannot go outside the network for care. There are no out-of-network benefits, except for emergency services. Refer to the medical benefits summary from Cigna for more details.
Medical | Copay High | |
---|---|---|
IN-NETWORK | OAPin | |
Primary Residence | Nationwide | |
Calendar Year Deductible | Embedded | |
Individual | Family | $1000 | $2000 |
Plan Coinsurance | 80% | |
Out of Pocket Max (Coinsurance, Copays & Deductible Apply To Out of Pocket) | Embedded | |
Individual | Family | $4000 | $8000 |
Physician & Emergent Care | ||
Preventive Care | No charge | |
PCP | Specialist | CCN: $10 NCCN: $20 | CCN: $35 NCCN: $50 |
PCP Required | No | |
Referral Required | No | |
Virtual Visits | $5 | |
Convenience Care (i.e. CVS Minute Clinic) | $20 | |
Urgent Care | $50 | |
Emergency Room (In or out of network) | $500 | |
Hospitalization & Outpatient Care | ||
Inpatient | 20% after deductible | |
Outpatient | 20% after deductible | |
Physician Fees | 20% after deductible | |
Independent Facility Care | ||
Labs | No charge | |
X-rays | No charge | |
Complex Diagnostic Imaging | 20% after deductible | |
Prescription Drugs | Mandatory Generic | |
Deductible | $0 | |
Tier 1 | $10 | |
Tier 2 | $35 | |
Tier 3 | $60 | |
Specialty (GH, Self Injectable, etc) | $125 | |
Mail Order - 90 day supply | 2.5 x retail copay | |
OUT-OF-NETWORK | ||
Deductible Individual | Family | No benefits except emergency services | |
Plan Coinsurance | No benefits except emergency services | |
Out of Pocket Max | No benefits except emergency services | |
Office Charges | No benefits except emergency services | |
Facility Charges | No benefits except emergency services | |
Balance Billing | No benefits except emergency services |
CDHP Base Plan
This chart gives an overview of the medical Copay plans administered by Cigna. As a member of a Copay plan, you can use the doctors and hospitals within the Open Access Plus In (OAPIN) network, but cannot go outside the network for care. There are no out-of-network benefits, except for emergency services. Refer to the medical benefits summary from Cigna for more details.
Medical | CDHP Base | |
---|---|---|
IN-NETWORK | OAP | |
Primary Residence | Nationwide | |
Calendar Year Deductible | Non-Embedded | |
Individual | Family | $2000 | $4000 |
Plan Coinsurance | 80% | |
Out of Pocket Max (Coinsurance, Copays & Deductible Apply To Out of Pocket) | Embedded | |
Individual | Family | $4000 | $8000 |
Physician & Emergent Care | ||
Preventive Care | No charge | |
PCP | Specialist | 20% after deductible | |
PCP Required | No | |
Referral Required | No | |
Virtual Visits | $5 Deductible waived | |
Convenience Care (i.e. CVS Minute Clinic) | 20% after deductible | |
Urgent Care | 20% after deductible | |
Emergency Room (In or out of network) | 20% after deductible | |
Hospitalization & Outpatient Care | ||
Inpatient | 20% after deductible | |
Outpatient | 20% after deductible | |
Physician Fees | 20% after deductible | |
Independent Facility Care | ||
Labs | 20% after deductible | |
X-rays | 20% after deductible | |
Complex Diagnostic Imaging | 20% after deductible | |
Prescription Drugs | Mandatory Generic | |
Deductible | Medical deductible | |
Tier 1 | $10 after deductible | |
Tier 2 | $35 after deductible | |
Tier 3 | $60 after deductible | |
Specialty (GH, Self Injectable, etc) | $125 after deductible | |
Mail Order - 90 day supply | 2.5 x retail copay | |
OUT-OF-NETWORK | ||
Deductible Individual | Family | $4000 | $8000 |
Plan Coinsurance | 60% | |
Out of Pocket Max | $8000 | $16000 |
Office Charges | 40% after deductible | |
Facility Charges | 40% after deductible | |
Balance Billing | Yes |
CDHP High Plan
This chart gives an overview of the medical Copay plans administered by Cigna. As a member of a Copay plan, you can use the doctors and hospitals within the Open Access Plus In (OAPIN) network, but cannot go outside the network for care. There are no out-of-network benefits, except for emergency services. Refer to the medical benefits summary from Cigna for more details.
Medical | CDHP High | |
---|---|---|
IN-NETWORK | OAP | |
Primary Residence | Nationwide | |
Calendar Year Deductible | Non-Embedded | |
Individual | Family | $2000 | $4000 |
Plan Coinsurance | Your plan pays 100% | Your plan pays 80% |
Out of Pocket Max (Coinsurance, Copays & Deductible Apply To Out of Pocket) | Embedded | |
Individual | Family | $4000 | $8000 |
Physician & Emergent Care | ||
Preventive Care | No charge | |
PCP | Specialist | Deductible | |
PCP Required | No | |
Referral Required | No | |
Virtual Visits | $5 Deductible waived | |
Convenience Care (i.e. CVS Minute Clinic) | Deductible | |
Urgent Care | Deductible | |
Emergency Room (In or out of network) | Deductible | |
Hospitalization & Outpatient Care | ||
Inpatient | Deductible | |
Outpatient | Deductible | |
Physician Fees | Deductible | |
Independent Facility Care | ||
Labs | Deductible | |
X-rays | Deductible | |
Complex Diagnostic Imaging | Deductible | |
Prescription Drugs | Mandatory Generic | |
Deductible | Medical deductible | |
Tier 1 | $10 after deductible | |
Tier 2 | $35 after deductible | |
Tier 3 | $60 after deductible | |
Specialty (GH, Self Injectable, etc) | $125 after deductible | |
Mail Order - 90 day supply | 2.5 x retail copay | |
OUT-OF-NETWORK | ||
Deductible Individual | Family | $4000 | $8000 |
Plan Coinsurance | 80% | |
Out of Pocket Max | $8000 | $16000 |
Office Charges | 20% after deductible | |
Facility Charges | 20% after deductible | |
Balance Billing | Yes |
CDHP SureFit Plan
This chart provides an overview of the medical CDHP plans administered by Cigna. As a member of a CDHP SureFit plan, you can use the doctors and hospitals within the SureFit network. You have access to doctors and hospitals within the SureFit network but cannot go outside the network for care. There are no out-of-network benefits, except for emergency services. Refer to the medical benefits summary from Cigna for more details.
Medical | CDHP Surefit Non-Embedded | |
---|---|---|
IN-NETWORK | SureFit | |
Primary Residence | Lake, Orange, Osceola, Seminole County and Polk County Florida | |
Calendar Year Deductible | Non-Embedded | |
Individual | Family | $2250 | $4500 |
Plan Coinsurance | 70% | |
Out of Pocket Max (Coinsurance, Copays & Deductible Apply To Out of Pocket) | Embedded | |
Individual | Family | $4500 | $9000 |
Physician & Emergent Care | ||
Preventive Care | No charge | |
PCP | Specialist | 30% after deductible | |
PCP Required | Yes | |
Referral Required | Yes | |
Virtual Visits | $5 Deductible waived | |
Convenience Care (i.e. CVS Minute Clinic) | 30% after deductible | |
Urgent Care | 30% after deductible | |
Emergency Room (In or out of network) | 30% after deductible | |
Hospitalization & Outpatient Care | ||
Inpatient | 30% after deductible | |
Outpatient | 30% after deductible | |
Physician Fees | 30% after deductible | |
Independent Facility Care | ||
Labs | 30% after deductible | |
X-rays | 30% after deductible | |
Complex Diagnostic Imaging | 30% after deductible | |
Prescription Drugs | Mandatory Generic | |
Deductible | Medical deductible | |
Tier 1 | $10 after deductible | |
Tier 2 | $35 after deductible | |
Tier 3 | $60 after deductible | |
Specialty (GH, Self Injectable, etc) | $125 after deductible | |
Mail Order - 90 day supply | 2.5 x retail copay | |
OUT-OF-NETWORK | ||
Deductible Individual | Family | No benefits except emergency services | |
Plan Coinsurance | No benefits except emergency services | |
Out of Pocket Max | No benefits except emergency services | |
Office Charges | No benefits except emergency services | |
Facility Charges | No benefits except emergency services | |
Balance Billing | No benefits except emergency services |
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