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| Benefits | In-Network | Out-Of-Network | |||||||||||
| Coinsurance | 80% | 60% | |||||||||||
| Out-Of-Pocket Maximum Single | $3,000 | $6,000 | |||||||||||
| Out-Of-Pocket Maximum Family | $6,000 | $12,000 | |||||||||||
| Deductible-Single | $1,000 | $2,000 | |||||||||||
| Deductible-Family | $2,000 | $4,000 | |||||||||||
| Lifetime Maximum Benefit | Unlimited | $1,000,000 | |||||||||||
| Preventive Care - Routine Medical Exam | $35/$45 copay | In network only | |||||||||||
| Primary Care Physican Visit | $35 copay | 60% after deductible | |||||||||||
| Speciality Care Physician Copay | $45 copay | 60% after deductible | |||||||||||
| Prescription Drug Generic Copay | $10 | In network only | |||||||||||
| Prescription Drug Brand Copay | $20 | In network only | |||||||||||
| Prescription Drug NonFormulary Copay | $40 | In network only | |||||||||||
| The above information is a courtesy of CIGNA . Please refer to your insurance certificate to determine the exact terms, conditions, and scope of coverage including all exclusions and limitations. This summary is designed as a partial description of your plan and in no way represents all benefits, limitations, or exclusions. |
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