Base PPO Plan
Preferred Provider Organization · Administered by Cigna · Network: Cigna
Base PPO Plan
Bi-weekly Premiums
| Tier | Employee Cost |
|---|---|
| Employee Only | $25.45 |
| Employee + Spouse | $403.84 |
| Employee + Children | $348.21 |
| Family | $743.64 |
Employee Only
Employee Cost$25.45
Employee + Spouse
Employee Cost$403.84
Employee + Children
Employee Cost$348.21
Family
Employee Cost$743.64
Deductible & Out-of-Pocket
| Benefit | In-Network | Out-of-Network |
|---|---|---|
| Annual deductible (Individual / Family) | $2,500 / $5,000 | $10,000 / $20,000 |
| Out-of-pocket maximum (Individual / Family) | $6,000 / $12,000 | $12,000 / $24,000 |
| Preventive care | Covered 100% | 30%* |
| Primary physician office visit | $25 copay | 30%* |
| Specialist office visit | $50 copay* | 30%* |
| Telehealth | Covered 100% | Not covered |
| Inpatient hospital services | $750 copay per day (3-day max) | 30%* |
| Outpatient hospital services (lab, x-ray, diagnostic) | 10%* | 30%* |
| Advanced diagnostics | $750 copay | 40%* |
| Urgent care | $50 copay | 30%* |
| Emergency room care | $500 copay* | $500 copay* |
Annual deductible (Individual / Family)
In-Network$2,500 / $5,000
Out-of-Network$10,000 / $20,000
Out-of-pocket maximum (Individual / Family)
In-Network$6,000 / $12,000
Out-of-Network$12,000 / $24,000
Preventive care
In-NetworkCovered 100%
Out-of-Network30%*
Primary physician office visit
In-Network$25 copay
Out-of-Network30%*
Specialist office visit
In-Network$50 copay*
Out-of-Network30%*
Telehealth
In-NetworkCovered 100%
Out-of-NetworkNot covered
Inpatient hospital services
In-Network$750 copay per day (3-day max)
Out-of-Network30%*
Outpatient hospital services (lab, x-ray, diagnostic)
In-Network10%*
Out-of-Network30%*
Advanced diagnostics
In-Network$750 copay
Out-of-Network40%*
Urgent care
In-Network$50 copay
Out-of-Network30%*
Emergency room care
In-Network$500 copay*
Out-of-Network$500 copay*
Prescription Drugs
Retail (30-day supply)
| Tier | In-Network | Out-of-Network |
|---|---|---|
| Generic | $10 copay | 50% |
| Brand preferred | $35 copay | 50% |
| Brand non-preferred | $75 copay | 50% |
| Specialty | $150 copay | 50% |
Generic
In-Network$10 copay
Out-of-Network50%
Brand preferred
In-Network$35 copay
Out-of-Network50%
Brand non-preferred
In-Network$75 copay
Out-of-Network50%
Specialty
In-Network$150 copay
Out-of-Network50%
Mail Order (90-day supply)
| Tier | In-Network | Out-of-Network |
|---|---|---|
| Generic | $25 copay | Not covered |
| Brand preferred | $88 copay | Not covered |
| Brand non-preferred | $188 copay | Not covered |
| Specialty (30-day only) | $150 copay | Not covered |
Generic
In-Network$25 copay
Out-of-NetworkNot covered
Brand preferred
In-Network$88 copay
Out-of-NetworkNot covered
Brand non-preferred
In-Network$188 copay
Out-of-NetworkNot covered
Specialty (30-day only)
In-Network$150 copay
Out-of-NetworkNot covered
Notes
- Preventive care is covered 100% in-network.
- Higher benefit coverage when visiting in-network providers.
- Use myCigna app to access your virtual ID card.
Cigna - Medical/Rx