Plan Details
Plan Name	Cigna PPO (HBC)
Effective Dates	Jan 01, 2024 to Jan 01, 2025
Benefits	In-Network	Out-of-Network
Annual Deductible/Individual	$1750 $2,000 per individual in a family	$7000 $8,000 per individual in a family
Annual Deductible/Family	$3,500	$14,000
Coinsurance	20%	40%
Office Visit/Exam	$45	40% after deductible
Outpatient Specialist Visit	$90	40% after deductible
Annual Out-of-Pocket Limit/Individual	$5,000	$15,000
Annual Out-of-Pocket Limit/Family	$10,000	$30,000
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	$200 copay waived if admitted	$200 copay waived if admitted
Urgent Care Facility	$90	40% after deductible
Prescription Drug Deductible	$0	$0
Prescription Drugs - Generic	$10	Not covered
Prescription Drugs - Brand (Formulary/Preferred)	30% up to $200	Not covered
Prescription Drugs - Brand (Non-Formulary/Non-preferred)	50% up to $400	Not covered
Prescription Drugs - Specialty	N/A	N/A
Chiropractic Services	$45 up to 30 days per year	40% after deductible
Acupuncture	Not covered	Not covered