Buy-Up PPO Plan
Preferred Provider Organization · Administered by Cigna · Network: Cigna
Buy-Up PPO Plan
Bi-weekly Premiums
| Tier | Employee Cost |
|---|---|
| Employee Only | $54.38 |
| Employee + Spouse | $494.91 |
| Employee + Children | $438.35 |
| Family | $873.61 |
Employee Only
Employee Cost$54.38
Employee + Spouse
Employee Cost$494.91
Employee + Children
Employee Cost$438.35
Family
Employee Cost$873.61
Deductible & Out-of-Pocket
| Benefit | In-Network | Out-of-Network |
|---|---|---|
| Annual deductible (Individual / Family) | $1,500 / $3,000 | $5,000 / $10,000 |
| Out-of-pocket maximum (Individual / Family) | $5,000 / $10,000 | $10,000 / $20,000 |
| Preventive care | Covered 100% | 40%* |
| Primary physician office visit | $25 copay | 40%* |
| Specialist office visit | $50 copay | 40%* |
| Telehealth | Covered 100% | Not covered |
| Inpatient hospital services | 20%* | 40%* |
| Outpatient hospital services (lab, x-ray, diagnostic) | 20%* | 40%* |
| Advanced diagnostics | $500 copay | 40%* |
| Urgent care | $50 copay | 40%* |
| Emergency room care | $500 copay | $500 copay |
Annual deductible (Individual / Family)
In-Network$1,500 / $3,000
Out-of-Network$5,000 / $10,000
Out-of-pocket maximum (Individual / Family)
In-Network$5,000 / $10,000
Out-of-Network$10,000 / $20,000
Preventive care
In-NetworkCovered 100%
Out-of-Network40%*
Primary physician office visit
In-Network$25 copay
Out-of-Network40%*
Specialist office visit
In-Network$50 copay
Out-of-Network40%*
Telehealth
In-NetworkCovered 100%
Out-of-NetworkNot covered
Inpatient hospital services
In-Network20%*
Out-of-Network40%*
Outpatient hospital services (lab, x-ray, diagnostic)
In-Network20%*
Out-of-Network40%*
Advanced diagnostics
In-Network$500 copay
Out-of-Network40%*
Urgent care
In-Network$50 copay
Out-of-Network40%*
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 | Covered under Tier 3 | Covered under Tier 3 |
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-NetworkCovered under Tier 3
Out-of-NetworkCovered under Tier 3
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) | Covered under Tier 3 | Covered under Tier 3 |
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-NetworkCovered under Tier 3
Out-of-NetworkCovered under Tier 3
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