| BENEFIT DESCRIPTION |
IN-NETWORK |
OUT-OF-NETWORK |
| Calendar Year Deductible |
$400 (2x Family) |
$800 (2x Family) |
|
Services Rendered in Physician's Office |
| Office Visits - Primary Care |
$20 Co-pay/100% |
65% |
| Office Visits - Specialist |
$40 Co-pay/100% |
65% |
| Surgery/Anest. |
$20 Co-pay/100% |
65% |
| Child Well Care/Immunizations (to age 6) |
$20 Co-pay/100% |
Not Covered |
| Adult Well Care (includes children age 6 and up) |
$20Co-pay/100% $1500 Annual Limit |
Not Covered |
| X-Ray & Lab |
$20Co-pay/100% |
65% |
| Psych/Mental/Nervous |
85%/25 visits |
65%/25 visits |
| Substance |
85%/$100/25 Visits |
65%/$100/25 Visits |
|
Physician Services Outside Physician Office |
| Surgery/Anest. |
85% |
65% |
| Maternity |
85% |
65% |
| Newborn Care |
85% |
65% |
| X-Ray & Lab |
85% |
65% |
| Hospital Visits |
85% |
65% |
|
Hospital/Facility Services |
| Semi-Private Room |
85% |
65% |
| Private Room |
85% SP Rate |
65% SP Rate |
| Intensive/Coronary Care |
85% |
65% |
| Nursery Care |
85% |
65% |
| Drugs & Medications |
85% |
65% |
| X-Ray & Lab |
85% |
65% |
| Physical Therapy |
85% |
65% |
| Emergency Room |
$250 Co-pay/100% |
65% |
| Surgery/Anest. |
85% |
65% |
| Inpatient Psych/Substance |
85%/30 Day Limit |
65%/30 Day Limit |
|
Other Services/Supplies |
|
Prescription Drugs
- RX Prime Card/30 day
-Tel-Drug Mail Order/90 day supply
|
30% Co-Insurance up to $7.00 per RX Generic
40% Co-Insurance up to $50.00 per RX Preferred
50% Co-Insurance up to $75.00 per RX Non - Preferred
$2000 Combined |
85% |
| Convalescent Facility |
85% Semi-Private Rate/100 Day Limit |
| Durable Medical Equipment |
85% |
85% |
| Prosthetic/Orthopedic Appl. |
85% |
85% |
| Vision Exams/Lens |
Not Covered |
Not Covered |
| Ambulance |
85% |
65% |
| Skilled Private Nursing |
85% |
65% |
| Home Health Care |
100%/$25,000 Limit |
100%/$25,000 Limit |
| Hospice |
100%/$25,000 Limit |
100%/$25,000 Limit |
| Podiatric Care |
$40 Co-pay/50 Visits |
50%/$40/50 Visits |
| Care of Spinal Conditions |
$40 Co-pay/50 Visits |
50%/$40/50 Visits |
| Non-Surgical TMJ & Related |
50%/$600 Lifetime |
50%/$600 Lifetime |
| Maximum Out-Of-Pocket |
$2,000 Individual
$4,000 Family
Excludes Calendar Year Deductible. Excludes Co-pays and 50% coverage areas. |
$4,000 Individual $8,000 Family
|
| Personal Health Solution |
- 24 Hours Health Line
- my Cigna.Com
- In-patient Pre-Certification
- Continued Hospital Stay
- Case Management
- Diabetes Drugs Free
|
|
|
|
Lifetime Maximums |
| Substance Abuse |
$10,000 |
| Non-Surgical TMJ |
$600 |
| Home Health Care |
$25,000 |
| Hospice |
$25,000 |
|
|
| All Other |
Lifetime |
