Medical - Cigna

Option 1

Option 2

Option 3

Option 4

Deductible 

Individual/Family (per calendar year)

$5,000/$10,000

$2,000/$4,000

$3,000/$6,000

$2,500/$5,000

Out-Of-Pocket max (includes deductible)
Individual/Family (per calendar year)

$6,000/$12,000

$6,500/$13,000

$6,350/$12,700

$4,000/$8,000

Co-insurance

80% paid by Cigna
20% paid by You

80% paid by Cigna
20% paid by You

80% paid by Cigna
20% paid by You

100% paid by Cigna
0% paid by You

Preventative Care

100% covered 

100% covered

100% covered

100% covered 

Office Visit
Primary Care Phy
Specialist
Telehealth

Ded/Coinsurance
Ded/Coinsurance
Ded/Coinsurance

$5 Copay
$100 Copay
$5 Copa

$30 Copay
$60 Copay
$30 Copay

$25 Copay
$50 Copay
$25 Copay

Retail Pharmacy Drug Coverage
Tier 1/Tier2/Tier3/Tier4

$10/$35/$60/NA
After Deductible

$5/$50/$100/$250
Rx Ded for All Tiers

$15/$40/$75

$15/$40/$75

Mail order Pharmacy Drug Coverage 1/Tier2/Tier3/Tier4

$25/$88/$150/NA
After Deductible

13/$125/$250/NA
Rx Ded for All Tiers

$38/$100/$188

$38/$100/$ 188

Urgent Care

Ded/Coinsurance

$50 Copay

$100 Copay

$100 Copay

Inpatient Hospital Care

Ded/Coinsurance

Ded/Coinsurance

Ded/Coinsurance

Deductible

Outpatient Hospital Care

Ded/Coinsurance

Ded/Coinsurance

Ded/Coinsurance

Deductible

Hi-Tech Diagnostics

Ded/Coinsurance

Ded/Coinsurance

Ded/Coinsurance

Deductible

Emergency Services

Ded/Coinsurance

$250 Copay + Coinsurance

$300 Copay

$300 Copay

Lifetime Maximum

Unlimited

Unlimited

Unlimited

Unlimited

OPTION 1 - WEEKLY RATES

EMPLOYEE ONLY

EMPLOYEE/SPOUSE

EMPLOYEE/CHILD(REN)

FAMILY

NON-TOBACCO RATE

$44.45

$209.88

$169.77

$335.20

TOBACCO RATE

$54.45

$219.88

$179.77

$345.20

OPTION 2 - WEEKLY RATES

EMPLOYEE ONLY

EMPLOYEE/SPOUSE

EMPLOYEE/CHILD(REN)

FAMILY

NON-TOBACCO RATE

$87.49

$308.08

$254.60

$475.19

TOBACCO RATE

$97.49

$318.08

$264.60

$485.19

OPTION 3 - WEEKLY RATES

EMPLOYEE ONLY

EMPLOYEE/SPOUSE

EMPLOYEE/CHILD(REN)

FAMILY

NON-TOBACCO RATE

$90.01

$313.92

$259.64

$483.55

TOBACCO RATE

$100.01


$323.92

$269.64

$493.55

OPTION 4 - WEEKLY RATES

EMPLOYEE ONLY

EMPLOYEE/SPOUSE

EMPLOYEE/CHILD(REN)

FAMILY

NON-TOBACCO RATE

$105.28

$349.35

$290.19

$534.25

TOBACCO RATE

115.28

$359.35

$300.19

$544.25