Page 6 - TVS 2021 Benefits Guide

Cigna Plan 1—HDHP/HSA Cigna Plan 2—PPO
In-Network Out-of-Network In-Network Out-of-Network
Hospital Services
Inpatient 0% after deductible 30% after deductible 20% after deductible 40% after deductible
Outpatient 0% after deductible 30% after deductible 20% after deductible 40% after deductible
Emergency Room 0% after deductible 0% after deductible $75 copay; deductible $75 copay; deductible
waived; copay waived waived; copay waived
if admitted if admitted
Non-Emergency Care in an Not covered Not covered Not covered Not covered
Emergency Room
Chiropractic Care
Chiropractic 0% after deductible 30% after deductible $65 copay; 30% after deductible
deductible waived
Prescription Drugs
Retail—Supply Limit 30-day supply 30-day supply
Generic $10 copay
Deductible, then
Preferred Brand covered at 100% 30% after deductible $30 copay 40% after copay
Non-Preferred Brand $50 copay
Mail Order—Supply Limit 90-day supply 90-day supply
Generic $25 copay
Deductible, then
Preferred Brand covered at 100% Not covered $75 copay Not covered
Non-Preferred Brand $125 copay

Please refer to your plan documents for more detailed information.

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