Cigna Health and Life Insurance Company

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Plan Overview

Combined Medical and Drug Deductible	Individual: $1,500.00 Family: $3000 Per Person: $1500
Combined Medical and Drug Out of Pocket Maximum	Individual: $7,800.00 Family: $15600 Per Person: $7800

Office Visit

Primary Doctor	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Includes Mental Health Office Visits and Substance Use Disorder Office Visits. Refer to the policy for more information about Virtual Care Services.
Specialist	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: You pay a copayment for each 30 day supply. Up to a 30-day supply at any Participating Pharmacy or up to a 90-day supply at a Designated 90-day Pharmacy. Refer to the prescription drug list for more information.
Non Preferred Brand Drugs	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: You pay a copayment for each 30 day supply. Up to a 30-day supply at any Participating Pharmacy or up to a 90-day supply at a Designated 90-day Pharmacy. Refer to the prescription drug list for more information.
Generic Drugs	CoPay: $15.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: You pay a copayment for each 30 day supply. Up to a 30-day supply at any Participating Pharmacy, or up to a 90-day supply at a Designated 90-day Pharmacy. Refer to the prescription drug list for more information.
Specialty Drugs	CoPay: $250.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Including other high cost drugs. You pay a copayment for each 30 day supply. Up to a 30-day supply at any Participating Pharmacy or up to a 90-day supply at a Designated 90-day Pharmacy. Refer to the prescription drug list for more information.

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 25.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 25.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 25.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Out-of-Network: You pay the same level as In-network if it is an emergency as defined in your plan, otherwise Not covered.
Urgent Care Facility	CoPay: $45.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Out-of-network: You pay the same level as In-network if it is an emergency as defined in your plan, otherwise Not covered.

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 25.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 25.00% Coinsurance after deductible Covered: Covered

Vision

Routine Eye Exams for Children

CoPay: Not Applicable
CoInsurance: No Charge
Covered: Covered
Limit Quantity: 1
Limit Unit : Visit(s) per Year
Benefit Explanation: Children up to age 19. Limited to 1 visit per 12 month period.

Major Dental Care

Routine Dental Checkups for Children

Covered: Not Covered

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Cigna HealthCare of Arizona, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of North Carolina, Inc. and Cigna Dental Health, Inc. The Cigna name, logo and other Cigna marks are owned by Cigna Intellectual Property, Inc.