HDHP Plan
High Deductible Health Plan · Administered by Cigna · Network: Cigna
HDHP Plan
Plan Details
HSA Eligible
Yes
FSA Eligible
No
Bi-weekly Premiums
| Tier | Employee Cost |
|---|---|
| Employee Only | $0.00 |
| Employee + Spouse | $300.46 |
| Employee + Children | $271.44 |
| Family | $484.87 |
Employee Only
Employee Cost$0.00
Employee + Spouse
Employee Cost$300.46
Employee + Children
Employee Cost$271.44
Family
Employee Cost$484.87
Deductible & Out-of-Pocket
| Benefit | In-Network | Out-of-Network |
|---|---|---|
| Annual deductible (Individual / Family) | $2,500 / $5,000 | $5,000 / $10,000 |
| Out-of-pocket maximum (Individual / Family) | $7,500 / $9,200 | $15,000 / $18,400 |
| Preventive care | Covered 100% | 40% after deductible |
| Primary physician office visit | 20% after deductible | 40% after deductible |
| Specialist office visit | 20% after deductible | 40% after deductible |
| Telehealth | Covered 100% after deductible | Not covered |
| Inpatient hospital services | 20% after deductible | 40% after deductible |
| Outpatient hospital services (lab, x-ray, diagnostic) | 20% after deductible | 40% after deductible |
| Advanced diagnostics | $500 copay after deductible | 40% after deductible |
| Urgent care | 20% after deductible | 40% after deductible |
| Emergency room care | $500 copay, then 20% after deductible | $500 copay, then 20% after deductible |
Annual deductible (Individual / Family)
In-Network$2,500 / $5,000
Out-of-Network$5,000 / $10,000
Out-of-pocket maximum (Individual / Family)
In-Network$7,500 / $9,200
Out-of-Network$15,000 / $18,400
Preventive care
In-NetworkCovered 100%
Out-of-Network40% after deductible
Primary physician office visit
In-Network20% after deductible
Out-of-Network40% after deductible
Specialist office visit
In-Network20% after deductible
Out-of-Network40% after deductible
Telehealth
In-NetworkCovered 100% after deductible
Out-of-NetworkNot covered
Inpatient hospital services
In-Network20% after deductible
Out-of-Network40% after deductible
Outpatient hospital services (lab, x-ray, diagnostic)
In-Network20% after deductible
Out-of-Network40% after deductible
Advanced diagnostics
In-Network$500 copay after deductible
Out-of-Network40% after deductible
Urgent care
In-Network20% after deductible
Out-of-Network40% after deductible
Emergency room care
In-Network$500 copay, then 20% after deductible
Out-of-Network$500 copay, then 20% after deductible
Prescription Drugs
Retail (30-day supply)
| Tier | In-Network | Out-of-Network |
|---|---|---|
| Generic | $10 copay after deductible | 50% after deductible |
| Brand preferred | $35 copay after deductible | 50% after deductible |
| Brand non-preferred | $75 copay after deductible | 50% after deductible |
| Specialty | $150 copay after deductible | 50% after deductible |
Generic
In-Network$10 copay after deductible
Out-of-Network50% after deductible
Brand preferred
In-Network$35 copay after deductible
Out-of-Network50% after deductible
Brand non-preferred
In-Network$75 copay after deductible
Out-of-Network50% after deductible
Specialty
In-Network$150 copay after deductible
Out-of-Network50% after deductible
Mail Order (90-day supply)
| Tier | In-Network | Out-of-Network |
|---|---|---|
| Generic | $25 copay after deductible | Not covered |
| Brand preferred | $88 copay after deductible | Not covered |
| Brand non-preferred | $188 copay after deductible | Not covered |
| Specialty (30-day only) | $150 copay after deductible | Not covered |
Generic
In-Network$25 copay after deductible
Out-of-NetworkNot covered
Brand preferred
In-Network$88 copay after deductible
Out-of-NetworkNot covered
Brand non-preferred
In-Network$188 copay after deductible
Out-of-NetworkNot covered
Specialty (30-day only)
In-Network$150 copay after deductible
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