Plan Details
Plan Name Cigna PPO (HBC)
Effective Dates Jan 01, 2023 to Dec 31, 2023
Benefits In-Network Out-of-Network
Annual Deductible/Individual $1000 $4000
Annual Deductible/Family $2000 $8000
Coinsurance 85% 60% after the deductible
Office Visit/Exam $30 copay 60% after the deductible
Outpatient Specialist Visit $60 copay 60% after the deductible
Annual Out-of-Pocket Limit/Individual $3000 $8000
Annual Out-of-Pocket Limit/Family $6000 $16000
Deductible Included in Out-of-Pocket Limits Yes Yes
Lifetime Plan Maximum Unlimited Unlimited
Preventive Care 100% 60% after the deductible
Preventive Screenings 100% 60% after the deductible
Well-Child Care 100% 60% after the deductible
Immunizations 100% 60% after the deductible
Well Woman Exams 100% 60% after the deductible
Mammograms 100% 60% after the deductible
Adult Periodic Exams with Preventive Tests 100% 60% after the deductible
Inpatient Hospitalization $500 copay/admission, plus 85% coinsurance 60% after the deductible
Semi-Private Room & Board; Including Services and Supplies $500 copay/admission, plus 85% coinsurance 60% after the deductible
Surgical Services Outpatient Facility Charge $250 copay/visit, plus 85% coinsurance. Deductible does not apply 60% after the deductible
Emergency Room $200 per visit $200 per visit
Urgent Care Facility $60 per visit 60% after the deductible
Prescription Drug Deductible N/A Not Covered
Prescription Drugs - Generic $10 Not covered
Prescription Drugs - Brand (Formulary/Preferred) 70% coinsurance/prescription, up to a $200 maximum (retail), after the deductible Not covered
Prescription Drugs - Brand (Non-Formulary/Non-preferred) 50% coinsurance/prescription, up to a $400 maximum (retail) after the deductible after the deductible Not covered
Prescription Drugs - Number of Days Supply 30 days Not Covered
Prescription Drugs Mail Order - Generic $20 after the deductible Not covered
Prescription Drugs Mail Order - Brand (Formulary/Preferred) 70% coinsurance/prescription, after deductible up to a $400 maximum, after the deductible Not covered
Prescription Drugs Mail Order - Brand (Non-Formulary/Non-preferred) 50% coinsurance/prescription, after deductible up to a $800 maximum, after the deductible Not covered
Prescription Drugs Mail Order - Number of Days Supply for Mail Order 90 days Not Covered
Durable Medical Equipment & Prosthetic Devices 85% after the deductible 60% after the deductible
Chiropractic Services $60 copay, deductible does not apply Covered up to 30 visits 60% after the deductible Covered up to 30 visits
Acupuncture Not covered Not covered
Outpatient Rehabilitative Physical Therapy $60 copay. Covered up to 60 visits 60% after the deductible. Covered up to 60 visits