Comprehensive Health Plans (EPOs) CIGNA Network

Self-Funded Plans (EPOs - For Plans that access the Cigna PPO Network)

For Employer Groups (51+) Self-Funded EPO and HSA Plan Options.

BENEFITS EPO Bronze Level 2 with HSA
For plans that access the Cigna PPO Network
EPO Bronze Level 2
For plans that access the Cigna PPO Network
EPO $40 Co-pay
For plans that access the Cigna PPO Network
EPO $20 Co-pay
For plans that access the Cigna PPO Network
Member Pays Member Pays Member Pays Member Pays
In Network In Network In Network In Network
MEDICAL PLAN PROVISIONS
Annual Medical Deductible $5,000 / Person
$10,000 / Family
$5,000 / Person
$10,000 / Family
None None
Annual Medical Out-of-Pocket Maximum
(The Member's Deductible, Copayments, and Coinsurance apply to the Annual Out-of-Pocket Maximum)
$6,250/ Person
$12,500 / Family
$6,250/ Person
$12,500 / Family
$3,000 / Person
$6,000 / Family
$1,500 / Person
$3,000 / Family
Amounts in Excess of Negotiated Rates /
Reasonable and Allowed Amounts
For Participating Providers, the contract generally prohibits the provider from charging more than the Reasonable & Allowed amount for covered services. However, the Member will be responsible for the Deductible, Copayments, and Coinsurance. For Participating Providers, the contract generally prohibits the provider from charging more than the Reasonable & Allowed amount for covered services. However, the Member will be responsible for the Deductible, Copayments, and Coinsurance. For Participating Providers, the contract generally prohibits the provider from charging more than the Reasonable & Allowed amount for covered services. However, the Member will be responsible for the Deductible, Copayments, and Coinsurance. For Participating Providers, the contract generally prohibits the provider from charging more than the Reasonable & Allowed amount for covered services. However, the Member will be responsible for the Deductible, Copayments, and Coinsurance.
Lifetime Maximum None None None None
Dependent Coverage To age 26 To age 26 To age 26 To age 26
MEDICAL SERVICES
PHYSICIAN SERVICES In Network In Network In Network In Network
Primary Care Office Visits $60 Copayment per visit after Annual Deductible $60 Copayment per visit after Annual Deductible $40 Copayment per visit $20 Copayment per visit
Specialist Care Office Visits $60 Copayment per visit after Annual Deductible $60 Copayment per visit after Annual Deductible $40 Copayment per visit $20 Copayment per visit
Other Physician Services performed in the office -
Including Diagnostic Services, Office Surgery, and Radiology Services
$60 Copayment per visit after Annual Deductible $60 Copayment per visit after Annual Deductible $40 Copayment per visit $20 Copayment per visit
Physician Services in a Facility
(Hospital, Outpatient Surgery, Emergency Room)
$60 Copayment per visit after Annual Deductible $60 Copayment per visit after Annual Deductible $40 Copayment per visit $20 Copayment per visit
Urgent Care $60 Copayment per visit after Annual Deductible $60 Copayment per visit after Annual Deductible $40 Copayment per visit $20 Copayment per visit
MATERNITY In Network In Network In Network In Network
Physician Services (Office Visits) $60 Copayment per visit after Annual Deductible $60 Copayment per visit after Annual Deductible $40 Copayment per visit $20 Copayment per visit
PREVENTATIVE CARE In Network In Network In Network In Network
Benefits for Children
New Born Circumcision No Copayment No Copayment No Copayment No Copayment
Well Child Care Office Visits
0 to 11 Months (6 "Well-baby visits")
1 to 4 Years (7 "Well-child visits")
5 to 17 Years (1 "Well-child visit" / year)
No Copayment No Copayment No Copayment No Copayment
Well Child Care Immunizations
(As recommended by Bright Futures project)
No Copayment No Copayment No Copayment No Copayment
Well Child Lab Tests
(As recommended by Bright Futures project)
No Copayment No Copayment No Copayment No Copayment
Adult Preventative Care Screening / Testing
Adults, One (1) Physical Exam per Benefit Year to obtain recommended Preventative and Diagnostic Services No Copayment No Copayment No Copayment No Copayment
Immunization Services for Adults
Immunizations - doses, recommended ages, and recommended populations vary per the recommendations of the Advisory Committee for Immunization Practices (ACIP)
No Copayment No Copayment No Copayment No Copayment
Prostate Specific Antigen
(Men, One per CY, age 50 and under)
No Copayment No Copayment No Copayment No Copayment
Screenings such as Obesity, Blood Pressure, Cholesterol, Cancer, HIV, Alcohol Misuse No Copayment No Copayment No Copayment No Copayment
Counseling such as Contraception, BRCA, Breast Cancer Chemoprevention, Folic Acid Supplements No Copayment No Copayment No Copayment No Copayment
Woman's Preventative Care Services
Prescribed contraceptive methods, sterilization procedures and patient education, (supply and administration of Contraceptive IUDs, Implants and Injectables). (Pharmacy - Birth control pills, Diaphragms, emergency contraceptive pill through your pharmacy benefits) No Copayment No Copayment No Copayment No Copayment
Well Woman Exam per Benefit Year to obtain recommended Preventive and Diagnostic Services
(subject to all limitations as described under Covered Medical Benefits)
No Copayment No Copayment No Copayment No Copayment
Counseling such as Contraception, BRCA, Breast Cancer Chemoprevention, Folic Acid Supplements No Copayment No Copayment No Copayment No Copayment
Services for Pregnant Woman including but not limited to Anemia Screening, Rh Incompatibility Screenings, Breastfeeding: Comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women.
(Reimbursement of Non-participating breastfeeding supplies up to the amount of $200)
No Copayment No Copayment No Copayment No Copayment
Hospital / Facilities Services
Inpatient Room & Care
Semi-private room rate(including scheduled Maternity Care & Nursery stays beyond a mother's discharge) in an Acute or Skilled Nursing Facility seating)  **
30% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible $500 Copayment No Copayment
Outpatient / Ambulatory Surgery Services & Birthing Centers   ** 30% Coinsurance after Annual Deductible
(waived if admitted to Inpatient status)
30% Coinsurance after Annual Deductible
(waived if admitted to Inpatient status)
$250 Copayment per visit
(waived if admitted to Inpatient status)
$20 Copayment per visit
(waived if admitted to Inpatient status)
Other Outpatient Hospital Services
(Such as Cardiac, Pulmonary, PT/OT/ST)  **
30% Coinsurance after Annual Deductible
(waived if admitted to Inpatient status)
30% Coinsurance after Annual Deductible
(waived if admitted to Inpatient status)
$50 Copayment per visit
(waived if admitted to Inpatient status)
$20 Copayment per visit
(waived if admitted to Inpatient status)
Emergency Room Services $300 Copayment after Annual Deductible
(waived if admitted to Inpatient status)
$300 Copayment after Annual Deductible
(waived if admitted to Inpatient status)
$100 Copayment per visit
(waived if admitted to Inpatient status)
$100 Copayment per visit
(waived if admitted to Inpatient status)
DIAGNOSTIC SERVICES In Network In Network In Network In Network
Laboratory Services
Non Hospital Based  ** 30% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible $50 Copayment per visit No Copayment
Hospital Based   ** 30% Coinsurance after Annual Deductible plus Amounts that exceed the Reasonable and Allowed Amount 30% Coinsurance after Annual Deductible plus Amounts that exceed the Reasonable and Allowed Amount $50 Copayment per visit
(waived if admitted to Inpatient status)
No Copayment
Radiology & Radiation Oncology Services
Non Hospital Based 30% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible $50 Copayment per visit No Copayment
Hospital Based   ** 30% Coinsurance after Annual Deductible plus Amounts that exceed the Reasonable and Allowed Amount 30% Coinsurance after Annual Deductible plus Amounts that exceed the Reasonable and Allowed Amount $50 Copayment per visit
(waived if admitted to Inpatient status)
No Copayment
CT / MRI / MRA / PET Scans
Non Hospital Based  ** 30% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible $50 Copayment per visit No Copayment
Hospital Based   ** 30% Coinsurance after Annual Deductible plus Amounts that exceed the Reasonable and Allowed Amount 30% Coinsurance after Annual Deductible plus Amounts that exceed the Reasonable and Allowed Amount $50 Copayment per visit
(waived if admitted to Inpatient status)
No Copayment
MENTAL HEALTH
BEHAVIORAL HEALTH
SUBSTANCE ABUSE DISORDER
In Network In Network In Network In Network
INPATIENT
Hospital & Facility Services;
semi-private room rate   **
30% Coinsurance after Annual Deductible plus Amounts that exceed the Reasonable and Allowed Amount 30% Coinsurance after Annual Deductible plus Amounts that exceed the Reasonable and Allowed Amount $500 Copayment No Copayment
Psychiatrist & Psychologist Services $60 Copayment per visit after Annual Deductible $60 Copayment per visit after Annual Deductible $40 Copayment per visit after No Copayment
OUTPATIENT
Psychiatrist & Psychologist Services  ** $60 Copayment per visit after Annual Deductible $60 Copayment per visit after Annual Deductible $40 Copayment per visit after $20 Copayment per visit after
Psychological Testing   ** $60 Copayment per visit after Annual Deductible $60 Copayment per visit after Annual Deductible $40 Copayment per visit after $20 Copayment per visit after
OTHER SERVICES In Network In Network In Network In Network
Allergy Testing
(Including serum, injections, and administration)
30% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible $40 Copayment per visit $20 Copayment per visit
Ground Ambulance
** - (Non-emergent)
$300 Copayment after Annual Deductible $300 Copayment after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount $150 Copayment after Annual Deductible $50 Copayment after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount
Air Ambulance
** - (Non-emergent)
$300 Copayment after Annual Deductible plus Amounts that exceed the Reasonable and Allowed Amount $300 Copayment after Annual Deductible plus Amounts that exceed the Reasonable and Allowed Amount $150 Copayment $50 Copayment
Chemotherapy   ** $60 Copayment per visit after Annual Deductible $60 Copayment per visit after Annual Deductible $40 Copayment per visit $20 Copayment per visit
Dialysis and Supplies   ** 30% Coinsurance after Annual Deductible plus Amounts that exceed the Reasonable and Allowed Amount 30% Coinsurance after Annual Deductible plus Amounts that exceed the Reasonable and Allowed Amount $40 Copayment per visit No Copayment
Durable Medical Equipment   **
(Including Orthodics / Prosthetics)
30% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible $40 Copayment per visit $20 Copayment per visit
Enteral Nutrition Therapy   ** 30% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible $40 Copayment per visit No Copayment
Hearing Aid
(Limited to one (1) device per ear every five (5) years)
Maximum of $1,500 per covered device
30% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible $40 Copayment per visit No Copayment
Evaluations for the Use of Hearing Aids 30% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible $40 Copayment per visit $20 Copayment per visit
Home Health Services   **
(Maximum of 120 visits per year)
$60 Copayment per visit after Annual Deductible $60 Copayment per visit after Annual Deductible $40 Copayment per visit $20 Copayment per visit
Home Infusion Services   ** 30% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible $40 Copayment per visit $20 Copayment per visit
Hospice Services   ** $60 Copayment per visit after Annual Deductible $60 Copayment per visit after Annual Deductible $40 Copayment per visit $20 Copayment per visit
Human Growth Hormone
Genetic Testing / Counseling, Other   **
30% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible $40 Copayment per visit $20 Copayment per visit
Physical / Occupational Therapy   ** $60 Copayment per visit after Annual Deductible $60 Copayment per visit after Annual Deductible $40 Copayment per visit $20 Copayment per visit
Speech Therapy   ** $60 Copayment per visit after Annual Deductible $60 Copayment per visit after Annual Deductible $40 Copayment per visit $20 Copayment per visit
ALTERNATIVE CARE SERVICES In Network In Network In Network In Network
There is a Combined Visit Limit of 5 per Plan Year
Acupuncture - Chiropractic Care
Naturopathy - Massage Therapy
Not Covered Not Covered $40 Copayment $20 Copayment
VISION PLAN PROVISIONS
Vision Exam - Lenses - Frames
Contact Lenses - Fitting
Lasik Surgery in Lieu of Glasses
$250 per Year, per Covered Member $250 per Year, per Covered Member $250 per Year, per Covered Member $250 per Year, per Covered Member
PHARMACY PROVISIONS
Please refer to Member ID Card for Pharmacy Contact Information
Member Pays Member Pays Member Pays Member Pays
PHARMACY BENEFITS
Annual Pharmacy Deductible
(If applicable will display as Per Person / Per Family)
Combined with Medical Annual Deductible
$5,000 / $10,000
Combined with Medical Annual Deductible
$5,000 / $10,000
None None
Annual Pharmacy Out of Pocket Maximum
(If Pharmacy OOP Maximum is Separate from the Medical OOP Maximum will display as Per Person / Per Family)
Combined with Medical Annual Out of Pocket Maximum
$6,250 / $1,250
Combined with Medical Annual Out of Pocket Maximum
$6,250 / $1,250
Combined with Medical Annual Out of Pocket Maximum Combined with Medical Annual Out of Pocket Maximum
Lifetime Maximum
Preventative Prescription Services
Mandatory Generic Only - Preventative Prescription Services as defined by PPACA. In order for preventive medications to be covered at 100%, a prescription is required from your physician, including over-the-counter (OTC) drugs.
Prescription Drugs
Pharmacy Retail
Up to a 31 Day Supply
Generic Only - $0 Generic Only $0 Generic Only - $0 Generic Only $0
Non-Preventative Prescription Drugs
All prescriptions will be dispensed as Generic unless otherwise prescribed by your Physician.
Pharmacy Retail
Up to a 31 Day Supply
(Generic, Preferred, Non-preferred)
Generic - $15 Copayment
Preferred Brand - $50 Copayment
Non-Preferred Brand - $50 Copayment
Generic - $15 Copayment
Preferred Brand - $50 Copayment
Non-Preferred Brand - $50 Copayment
Generic - $15 Copayment
Preferred Brand - $35 Copayment
Non-Preferred Brand - $35 Copayment
Generic - $10 Copayment
Preferred Brand - $25 Copayment
Non-Preferred Brand - $25 Copayment
Prescription Drugs
Pharmacy Retail
Up to a 90 Day Supply
(Generic, Preferred, Non-preferred)
Generic - $45 Copayment
Preferred Brand - $150 Copayment
Non-Preferred Brand - $150 Copayment
Generic - $45 Copayment
Preferred Brand - $150 Copayment
Non-Preferred Brand - $150 Copayment
Generic - $45 Copayment
Preferred Brand - $105 Copayment
Non-Preferred Brand - $105 Copayment
Generic - $30 Copayment
Preferred Brand - $75 Copayment
Non-Preferred Brand - $75 Copayment
Prescription Drugs
Pharmacy Mail Order
90 Day Supply
(Generic, Preferred, Non-preferred)
Generic - $30 Copayment
Preferred Brand - $100 Copayment
Non-Preferred Brand - $100 Copayment
Generic - $30 Copayment
Preferred Brand - $100 Copayment
Non-Preferred Brand - $100 Copayment
Generic - $30 Copayment
Preferred Brand - $70 Copayment
Non-Preferred Brand - $70 Copayment
Generic - $20 Copayment
Preferred Brand - $50 Copayment
Non-Preferred Brand - $50 Copayment
Specialty Drug
(Generic, Preferred, Non-preferred)
Generic - $15 Copayment
Preferred Brand - $50 Copayment
Non-Preferred Brand - $50 Copayment
Generic - $15 Copayment
Preferred Brand - $50 Copayment
Non-Preferred Brand - $50 Copayment
Generic - $15 Copayment
Preferred Brand - $35 Copayment
Non-Preferred Brand - $35 Copayment
Generic - $10 Copayment
Preferred Brand - $25 Copayment
Non-Preferred Brand - $25 Copayment
Monthly Cost For Information on Rates or to speak with a representative, please contact Robert Clarke, President of Broker Services. at (661) 373-8922 or rclarke@ngiins.com
Employee Only $360.00 $348.00 $335.00 $317.00 $340.00
Employee + Spouse $680.00 $656.00 $635.00 $588.00 $645.00
Employee + Child(ren) $620.00 $595.00 $573.00 $545.00 $585.00
Employee + Family $1,210.00 $1,160.00 $1,110.00 $885.00 $1130.00
* - Coinsurance amount is based on an approved Reasonable and Allowed reimbursement level.
** - Services Require Prior Authorization / Precertification
*** - After Plan Deductible
This summary provides a condensed explanation of plan benefits. Certain limitations, restrictions and exclusions may apply. Please refer to the Plan Document for complete information on benefits. In the case of discrepancy between this summary and the language contained in the Plan Document, the latter will take precedence.

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