Plan Details
Plan Name	Cigna Choice CDHP (HBC)
Effective Dates	Jan 01, 2024 to Jan 01, 2025
Benefits	In-Network	Out-of-Network
Annual Deductible/Individual	$4000 ($6550 individual within a family)	Not Covered
Annual Deductible/Family	$8,000	Not Covered
Coinsurance	30%	Not covered
Office Visit/Exam	30% after deductible	Not covered
Outpatient Specialist Visit	30% after deductible	Not Covered
Annual Out-of-Pocket Limit/Individual	$6350 ($6550 individual within a family)	Not Covered
Annual Out-of-Pocket Limit/Family	$12,700	Not Covered
Preventive Care	0%	Not covered
Inpatient Hospitalization	30% after deductible	Not covered
Surgical Services Outpatient Facility Charge	30% after deductible	Not covered
Emergency Room	30% after deductible	30% after deductible
Urgent Care Facility	30% after deductible	Not Covered
Prescription Drug Deductible	Combined with medical deductible	Not Covered
Prescription Drugs - Generic	$10 after deductible	Not covered
Prescription Drugs - Brand (Formulary/Preferred)	30% up to $200 after deductible	Not covered
Prescription Drugs - Brand (Non-Formulary/Non-preferred)	50% up to $400 after deductible	Not covered
Prescription Drugs - Specialty	N/A	N/A
Chiropractic Services	30% after deductible up to 30 days per year	Not Covered
Acupuncture	Not covered	Not covered