Plan Details
Plan Name	Cigna Choice Plus CDHP (HBC)
Effective Dates	Jan 01, 2024 to Jan 01, 2025
Benefits	In-Network	Out-of-Network
Annual Deductible/Individual	$2,500	$6,250
Annual Deductible/Family	$5,000	$12,500
Coinsurance	20%	40%
Office Visit/Exam	20% after deductible	40% after deductible
Outpatient Specialist Visit	20% after deductible	40% after deductible
Annual Out-of-Pocket Limit/Individual	$5,000	$12,500
Annual Out-of-Pocket Limit/Family	$10,000	$25,000
Preventive Care	0%	40% after deductible
Inpatient Hospitalization	20% after deductible	40% after deductible
Surgical Services Outpatient Facility Charge	20% after deductible	40% after deductible
Emergency Room	20% after deductible	20% after deductible
Urgent Care Facility	20% after deductible	20% after deductible
Prescription Drug Deductible	Combined with medical deductible	none
Prescription Drugs - Generic	$10 after deductible	Not covered
Prescription Drugs - Brand (Formulary/Preferred)	30% after deductible up to $200	Not covered
Prescription Drugs - Brand (Non-Formulary/Non-preferred)	50% after deductible up to $400	Not covered
Prescription Drugs - Specialty	N/A	N/A
Chiropractic Services	20% after deductible up to 30 days per year	40% after deductible up to 30 days per year
Acupuncture	Not covered	Not covered