Comprehensive Health Plans (PPOs) CIGNA Network

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

For Employer Groups (51+). Self-Funded PPO Plan Options

BENEFITS PPO Premium
For plans that access the Cigna PPO Network
PPO Preferred
For plans that access the Cigna PPO Network
PPO Gold
For plans that access the Cigna PPO Network
PPO Gold H.S.A
For plans that access the Cigna PPO Network
PPO Bronze Level 1
For plans that access the Cigna PPO Network
Silver Level 1 (HSA)
For plans that access the Cigna PPO Network
Member Pays Member Pays Member Pays Member Pays Member Pays Member Pay
In Network Out of Network In Network Out of Network In Network Out of Network In Network Out of Network In Network Out of Network In Network Out of Network
MEDICAL PLAN PROVISIONS
Annual Medical Deductible $500 / Person
$1,500 / Family
$1,000 / Person
$3,000 / Family
$1,000 / Person
$3,000 / Family
$2,000 / Person
$6,000 / Family
$2,000 / Person
$6,000 / Family
$4,000 / Person
$12,000 / Family
$1,350 / Person
$2,700 / Family
$5,000 / Person
$10,000 / Family
$2,000 / Person
$6,000 / Family
$4,000 / Person
$12,000 / Family
$3,000 / Person
$6,000 / Family
$6,000 / Person
$12,000 / Family
Annual Medical Out-of-Pocket Maximum
(The Member's Deductible, Copayments, and Coinsurance apply to the Annual Out-of-Pocket Maximum)
$1,000 / Person
$3,000 / Family
$2,000 / Person
$6,000 / Family
$2,000 / Person
$6,000 / Family
$4,000 / Person
$12,000 / Family
$4,000 / Person
$12,000 / Family
$8,000 / Person
$24,000 / Family
$3,000 / Person
$6,000 / Family
$5,000 / Person
$10,000 / Family
$6,600 / Person
$13,200 / Family
$8,000 / Person
$24,000 / Family
$3,000 / Person
$6,000 / Family
$12,000 / Person
$24,000 / 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 Non-Participating Providers, the member will be responsible for the deductible, copayments, and coinsurance, as well as any amounts exceeding the Reasonable & Allowed amount. Any amounts in excess of the Reasonable & Allowed amount payable to Providers DO NOT apply to the Annual Deductible NOR the Annual Out-of-Pocket Maximum. 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 Non-Participating Providers, the member will be responsible for the deductible, copayments, and coinsurance, as well as any amounts exceeding the Reasonable & Allowed amount. Any amounts in excess of the Reasonable & Allowed amount payable to Providers DO NOT apply to the Annual Deductible NOR the Annual Out-of-Pocket Maximum. 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 Non-Participating Providers, the member will be responsible for the deductible, copayments, and coinsurance, as well as any amounts exceeding the Reasonable & Allowed amount. Any amounts in excess of the Reasonable & Allowed amount payable to Providers DO NOT apply to the Annual Deductible NOR the Annual Out-of-Pocket Maximum. 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 Non-Participating Providers, the member will be responsible for the deductible, copayments, and coinsurance, as well as any amounts exceeding the Reasonable & Allowed amount. Any amounts in excess of the Reasonable & Allowed amount payable to Providers DO NOT apply to the Annual Deductible NOR the Annual Out-of-Pocket Maximum. 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 Non-Participating Providers, the member will be responsible for the deductible, copayments, and coinsurance, as well as any amounts exceeding the Reasonable & Allowed amount. Any amounts in excess of the Reasonable & Allowed amount payable to Providers DO NOT apply to the Annual Deductible NOR the Annual Out-of-Pocket Maximum. 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 Non-Participating Providers, the member will be responsible for the deductible, copayments, and coinsurance, as well as any amounts exceeding the Reasonable & Allowed amount. Any amounts in excess of the Reasonable & Allowed amount payable to Providers DO NOT apply to the Annual Deductible NOR the Annual Out-of-Pocket Maximum.
Lifetime Maximum None None None None None None
Dependent Coverage 26 26 26 26 26 26
MEDICAL SERVICES
PHYSICIAN SERVICES In Network Out of Network In Network Out of Network In Network Out of Network In Network Out of Network In Network Out of Network In Network Out of Network
Primary Care Office Visits $10 Copayment per visit 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge $20 Copayment per visit after 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge $25 Copayment per visit after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge $25 Copayment per visit after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge $25 Copayment per visit after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge 0% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge
Specialist Care Office Visits $10 Copayment per visit 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge $20 Copayment per visit after 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge $25 Copayment per visit after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge $25 Copayment per visit after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge $25 Copayment per visit after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge 0% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge
Other Physician Services performed in the office -
Including Diagnostic Services, Office Surgery, and Radiology Services
10% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge 15% Coinsurance after Annual Deductible 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge 20% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge 20% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge 30% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge 0% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge
Physician Services in a Facility
(Hospital, Outpatient Surgery, Emergency Room)
10% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge 15% Coinsurance after Annual Deductible 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge 20% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge 20% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge 30% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge 0% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge
Urgent Care $20 Copayment per visit 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge $30 Copayment per visit 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge $35 Copayment per visit 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge $35 Copayment per visit 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge $50 Copayment per visit 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge 0% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge
MATERNITY In Network Out of Network In Network Out of Network In Network Out of Network In Network Out of Network In Network Out of Network In Network Out of Network
Physician Services (Office Visits) 10% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge 15% Coinsurance after Annual Deductible 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge 20% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge 20% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge 30% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge 0% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Charge
PREVENTATIVE CARE In Network Out of Network In Network Out of Network In Network Out of Network In Network Out of Network In Network Out of Network In Network Out of Network
Benefits for Children
New Born Circumcision No Copayment 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount
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 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount
Well Child Care Immunizations
(As recommended by Bright Futures project)
No Copayment 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount
Well Child Lab Tests
(As recommended by Bright Futures project)
No Copayment 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount
Adult Preventative Care Screening / Testing
Adults, One (1) Physical Exam per Benefit Year to obtain recommended Preventative and Diagnostic Services No Copayment 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount
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 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount
Prostate Specific Antigen
(Men, One per CY, age 50 and under)
No Copayment 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount
Screenings such as Obesity, Blood Pressure, Cholesterol, Cancer, HIV, Alcohol Misuse No Copayment 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount
Counseling such as Contraception, BRCA, Breast Cancer Chemoprevention, Folic Acid Supplements No Copayment 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount
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 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount
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 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount
Counseling such as Contraception, BRCA, Breast Cancer Chemoprevention, Folic Acid Supplements No Copayment 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount
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 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount No Copayment 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount
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)  **
$100 Copayment per Day up to 3 Days $100 Copayment per Day up to 3 Days after plus amounts that exceed the Reasonable and Allowed Amount $150 Copayment per Day up to 3 Days after Annual Deductible $150 Copayment per Day up to 3 Days after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount $200 Copayment per Day up to 3 Days $200 Copayment per Day up to 3 Days after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount $200 Copayment per Day up to 3 Days $200 Copayment per Day up to 3 Days after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 40% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge 0% Coinsurance after Annual Deductible 0% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge
Outpatient / Ambulatory Surgery Services & Birthing Centers   ** $100 Copayment after Annual Deductible
(waived if admitted to Inpatient status)
$100 Copayment after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount
(waived if admitted to Inpatient status)
$150 Copayment after Annual Deductible
(waived if admitted to Inpatient status)
$150 Copayment after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount
(waived if admitted to Inpatient status)
$200 Copayment after Annual Deductible
(Copayment waived if admitted to Inpatient status)
$200 Copayment plus amounts that exceed the Reasonable and Allowed Amount $200 Copayment after Annual Deductible
(Copayment waived if admitted to Inpatient status)
$200 Copayment plus amounts that exceed the Reasonable and Allowed Amount $400 Copayment after Annual Deductible
(Copayment waived if admitted to Inpatient status)
$400 Copayment plus amounts that exceed the Reasonable and Allowed Amount
(Copayment waived if admitted to Inpatient status)
0% Coinsurance after Annual Deductible 0% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge
Other Outpatient Hospital Services
(Such as Cardiac, Pulmonary, PT/OT/ST)  **
10% Coinsurance after Annual Deductible
(waived if admitted to Inpatient Status)
10% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable & Allowed Amount
(waived if admitted to Inpatient status)
15% Coinsurance after Annual Deductible
(waived if admitted to Inpatient Status)
15% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 20% Coinsurance after Annual Deductible
(waived if admitted to Inpatient Status)
20% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount
(waived if admitted to Inpatient Status)
20% Coinsurance after Annual Deductible
(waived if admitted to Inpatient Status)
20% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount
(waived if admitted to Inpatient Status)
40% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 0% Coinsurance after Annual Deductible 0% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Charge
Emergency Room Services $100 Copayment after Annual Deductible
(waived if admitted to Inpatient status)
$100 Copayment after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount
(waived if admitted to Inpatient status)
$150 Copayment
(waived if admitted to Inpatient status)
$150 Copayment after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount $200 Copayment after Annual Deductible
(Copayment waived if admitted to Inpatient status)
$200 Copayment plus amounts that exceed the Reasonable and Allowed Amount $200 Copayment after Annual Deductible
(Copayment waived if admitted to Inpatient status)
$200 Copayment plus amounts that exceed the Reasonable and Allowed Amount $500 Copayment
(waived if admitted to Inpatient status)
$500 Copayment plus amounts that exceed the Reasonable and Allowed Amount
(Copayment waived if admitted to Inpatient status)
$100 Copayment after Annual Deductible
(Copayment waived if admitted to Inpatient status)
$100 Copayment after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount
(waived if admitted to Inpatient status)
DIAGNOSTIC SERVICES In Network Out of Network In Network Out of Network In Network Out of Network In Network Out of Network In Network Out of Network In Network Out of Network
Laboratory Services In Network Out of Network
Non Hospital Based  ** No Copayment 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount No Copayment 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 30% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 0% Coinsurance After Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount
Hospital Based   ** 10% Coinsurance after Annual Deductible 10% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 15% Coinsurance after Annual Deductible 15% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 20% Coinsurance after Annual Deductible
(waived if admitted to Inpatient status)
20% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 20% Coinsurance after Annual Deductible
(waived if admitted to Inpatient status)
20% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 50% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 0% Coinsurance After Annual Deductible 0% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount
Radiology & Radiation Oncology Services
Non Hospital Based No Copayment 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount No Copayment 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 30% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 0% Coinsurance After Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount
Hospital Based   ** 10% Coinsurance after Annual Deductible 10% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 15% Coinsurance after Annual Deductible 15% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 20% Coinsurance after Annual Deductible
(waived if admitted to Inpatient status)
20% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 20% Coinsurance after Annual Deductible
(waived if admitted to Inpatient status)
20% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 50% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 0% Coinsurance After Annual Deductible 0% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount
CT / MRI / MRA / PET Scans
Non Hospital Based  ** No Copayment 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount No Copayment 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount No Copayment 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 30% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 0% Coinsurance After Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount
Hospital Based   ** 10% Coinsurance after Annual Deductible 10% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 15% Coinsurance after Annual Deductible 15% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 20% Coinsurance after Annual Deductible
(waived if admitted to Inpatient status)
20% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 20% Coinsurance after Annual Deductible
(waived if admitted to Inpatient status)
20% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 50% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 0% Coinsurance After Annual Deductible 0% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount
MENTAL HEALTH
BEHAVIORAL HEALTH
SUBSTANCE ABUSE DISORDER
In Network Out of Network In Network Out of Network In Network Out of Network In Network Out of Network In Network Out of Network In Network Out of Network
INPATIENT
Hospital & Facility Services;
semi-private room rate   **
$100 Copayment per Day up to 3 Days after Annual Deductible $100 Copayment per Day up to 3 Days after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount $150 Copayment per Day up to 3 Days after Annual Deductible $150 Copayment per Day up to 3 Days after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount $200 Copayment per Day up to 3 Days after Annual Deductible $200 Copayment per Day up to 3 Days after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount $200 Copayment per Day up to 3 Days after Annual Deductible $200 Copayment per Day up to 3 Days after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 40% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 0% Coinsurance after Annual Deductible 0% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount
Psychiatrist & Psychologist Services 10% Coinsurance after Annual Deductible 10% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 15% Coinsurance after Annual Deductible 15% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 20% Coinsurance after Annual Deductible 20% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 20% Coinsurance after Annual Deductible 20% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 30% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 0% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount
OUTPATIENT
Psychiatrist & Psychologist Services  ** $10 Copayment per visit 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount $20 Copayment per visit 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount $25 Copayment per visit 50%  (*) Plus amounts that exceed the Reasonable and Allowed Amount $25 Copayment per visit 50%  (*) Plus amounts that exceed the Reasonable and Allowed Amount 30% Coinsurance after Annual Deductible 50% Plus amounts that exceed the Reasonable and Allowed Amount 0% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount
Psychological Testing   ** 10% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 15% Coinsurance after Annual Deductible 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 20% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible   **  (*) 20% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible   **  (*) 30% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 0% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount
OTHER SERVICES In Network Out of Network In Network Out of Network In Network Out of Network In Network Out of Network In Network Out of Network In Network Out of Network
Allergy Testing
(Including serum, injections, and administration)
$10 Copayment per visit 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount $20 Copayment per visit 15% Coinsurance * plus amounts that exceed the Reasonable and Allowed Amount $25 Copayment per visit 50% Coinsurance plus amounts that exceed the Reasonable and Allowed Amount $25 Copayment per visit 50% Coinsurance plus amounts that exceed the Reasonable and Allowed Amount 30% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 0% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount
Ground Ambulance
** - (Non-emergent)
$150 Copayment after Annual Deductible $150 Copayment after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount $200 Copayment after Annual Deductible $200 Copayment after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount $250 Copayment after Annual Deductible $250 Copayment plus amounts that exceed the Reasonable and Allowed Amount $250 Copayment after Annual Deductible $250 Copayment plus amounts that exceed the Reasonable and Allowed Amount 50% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 0% Coinsurance after Annual Deductible 0% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount
Air Ambulance
** - (Non-emergent)
$150 Copayment after Annual Deductible $150 Copayment after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount $200 Copayment after Annual Deductible $200 Copayment after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount $250 Copayment after Annual Deductible $250 Copayment after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount $250 Copayment after Annual Deductible $250 Copayment after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 50% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 0% Coinsurance after Annual Deductible 0% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount
Chemotherapy   ** 10% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 15% Coinsurance after Annual Deductible 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 20% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 20% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 30% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 0% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount
Dialysis and Supplies   ** 10% Coinsurance after Annual Deductible 10% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 15% Coinsurance after Annual Deductible 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 20% Coinsurance after Annual Deductible 20% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 20% Coinsurance after Annual Deductible 20% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 40% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 0% Coinsurance after Annual Deductible 0% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount
Durable Medical Equipment   **
(Including Orthodics / Prosthetics)
10% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 15% Coinsurance after Annual Deductible 15% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 20% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 20% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 30% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 0% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount
Enteral Nutrition Therapy   ** 10% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 15% Coinsurance after Annual Deductible 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 20% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 20% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 30% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 0% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount
Hearing Aid
(Limited to one (1) device per ear every five (5) years)
Maximum of $1,500 per covered device
10% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 15% Coinsurance after Annual Deductible 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 20% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 20% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 30% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 0% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount
Evaluations for the Use of Hearing Aids 10% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 15% Coinsurance after Annual Deductible 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 20% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 20% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 30% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 0% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount
Home Health Services   **
(Maximum of 120 visits per year)
10% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 15% Coinsurance after Annual Deductible 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 20% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 20% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 30% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 0% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount
Home Infusion Services   ** 10% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 15% Coinsurance after Annual Deductible 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 20% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 20% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 30% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 0% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount
Hospice Services   ** $20 Copayment per visit 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount $30 Copayment per visit 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount $35 Copayment per visit 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount $35 Copayment per visit 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 30% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 0% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount
Human Growth Hormone
Genetic Testing / Counseling, Other   **
10% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 15% Coinsurance after Annual Deductible 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 20% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 20% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 30% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 0% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount
Physical / Occupational Therapy   ** 10% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount $30 Copayment per visit 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount $35 Copayment per visit 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount $35 Copayment per visit 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 30% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 0% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount
Speech Therapy   ** 10% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount $30 Copayment per visit 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount $35 Copayment per visit 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount $35 Copayment per visit 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 30% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 0% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount
ALTERNATIVE CARE SERVICES In Network Out of Network In Network Out of Network In Network Out of Network In Network Out of Network In Network Out of Network In Network Out of Network
There is a Combined Visit Limit of 5 per Plan Year
Acupuncture - Chiropractic Care
Naturopathy - Massage Therapy
$20 Copayment per visit 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount $30 Copayment per visit 40% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount $35 Copayment per visit 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount $35 Copayment per visit 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 30% Coinsurance after Annual Deductible 50% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount 0% Coinsurance after Annual Deductible 30% Coinsurance after Annual Deductible plus amounts that exceed the Reasonable and Allowed Amount
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 $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 Member Pays Member Pays
PHARMACY BENEFITS Participating Pharmacies Non-Participating Pharmacies Participating Pharmacies Non-Participating Pharmacies Participating Pharmacies Non-Participating Pharmacies Participating Pharmacies Non-Participating Pharmacies Participating Pharmacies Non-Participating Pharmacies Participating Pharmacies Non-Participating Pharmacies
Annual Pharmacy Deductible
(If applicable will display as Per Person / Per Family)
None Not Applicable None Not Applicable None Not Applicable Combined with Medical Annual Deductible Not Applicable None Not Applicable Combined with Medical Annual Deductible
$3,000 Individual/$6,000 Family
Not Applicable
Annual Pharmacy Out of Pocket Maximum
(If Pharmacy OOP Maximum is Separate from the Medical OOP Maximum will display as Per Person / Per Family)
$5,850 / $10,700 Not Applicable $4,850 / $7,700 Not Applicable $1,700 / $1,700 Not Applicable Combined with Medical Annual Out of Pocket Maximum Not Applicable Combined with the Medical Annual Out of Pocket Maximum Medical MOOP:
$6,600 Per Person / $13,200 Per Family
Not Applicable $3,650 / $7,300 Not Applicable
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 Not Covered Generic Only - $0 Not Covered Generic Only - $0 Not Covered Generic Only - $0 Not Covered Generic Only - $0 Not Covered Generic Only - $0 Not Covered
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 - $10 Copayment
Preferred Brand - $20 Copayment
Non-Preferred Brand - $35 Copayment
Not Covered Generic - $20 Copayment
Preferred Brand - $30 Copayment
Non-Preferred Brand - $45 Copayment
Not Covered Generic - $25 Copayment
Preferred Brand - $40 Copayment
Non-Preferred Brand - $55 Copayment
Not Covered Generic - $25 Copayment
Preferred Brand - $40 Copayment
Non-Preferred Brand - $55 Copayment
Not Covered Generic - $25 Copayment
Preferred Brand - $50 Copayment
Non-Preferred Brand - $75 Copayment
Not Covered Generic - $25 Copayment After Annual Deductible
Preferred Brand - $50 Copayment After Annual Deductible
Non-Preferred Brand - $75 Copayment After Annual Deductible
Not Covered
Prescription Drugs
Pharmacy Retail
Up to a 90 Day Supply
(Generic, Preferred, Non-preferred)
Generic - $30 Copayment
Preferred Brand - $60 Copayment
Non-Preferred Brand - $105 Copayment
Not Covered Generic - $60 Copayment
Preferred Brand - $90 Copayment
Non-Preferred Brand - $135 Copayment
Not Covered Generic - $75 Copayment
Preferred Brand - $120 Copayment
Non-Preferred Brand - $165 Copayment
Not Covered Generic - $75 Copayment
Preferred Brand - $120 Copayment
Non-Preferred Brand - $165 Copayment
Not Covered Generic - $75 Copayment
Preferred Brand - $150 Copayment
Non-Preferred Brand - $225 Copayment
Not Covered Generic - $75 Copayment After Annual Deductible
Preferred Brand - $150 Copayment After Annual Deductible
Non-Preferred Brand - $225 Copayment After Annual Deductible
Not Covered
Prescription Drugs
Pharmacy Mail Order
90 Day Supply
(Generic, Preferred, Non-preferred)
Generic - $20 Copayment
Preferred Brand - $40 Copayment
Non-Preferred Brand - $70 Copayment
Not Covered Generic - $40 Copayment
Preferred Brand - $60 Copayment
Non-Preferred Brand - $90 Copayment
Not Covered Generic - $50 Copayment
Preferred Brand - $80 Copayment
Non-Preferred Brand - $110 Copayment
Not Covered Generic - $50 Copayment
Preferred Brand - $80 Copayment
Non-Preferred Brand - $110 Copayment
Not Covered Generic - $50 Copayment
Preferred Brand - $100 Copayment
Non-Preferred Brand - $150 Copayment
Not Covered Generic - $50 Copayment After Annual Deductible
Preferred Brand - $100 Copayment After Annual Deductible
Non-Preferred Brand - $150 Copayment After Annual Deductible
Not Covered
Specialty Drug
(Generic, Preferred, Non-preferred)
Generic - $10 Copayment
Preferred Brand - $20 Copayment
Non-Preferred Brand - $35 Copayment
Not Covered Generic - $20 Copayment
Preferred Brand - $30 Copayment
Non-Preferred Brand - $45 Copayment
Not Covered Generic - $25 Copayment
Preferred Brand - $40 Copayment
Non-Preferred Brand - $55 Copayment
Not Covered Generic - $25 Copayment
Preferred Brand - $40 Copayment
Non-Preferred Brand - $55 Copayment
Not Covered Generic - $25 Copayment
Preferred Brand - $50 Copayment
Non-Preferred Brand - $75 Copayment
Not Covered Generic - $75 Copayment After Annual Deductible
Preferred Brand - $150 Copayment After Annual Deductible
Non-Preferred Brand - $225 Copayment After Annual Deductible
Not Covered
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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