Page 5 - TVS 2022 Benefits Guide
P. 5
2022 Benefits Guide
Cigna Plan 1—HDHP/HSA Cigna Plan 2—PPO
In-Network Out-of-Network In-Network Out-of-Network
Lifetime Maximum Unlimited Unlimited Unlimited Unlimited
Calendar Year Deductible
Individual $2,200 $4,500 $1,500 $3,000
Family $4,400 $9,000 $3,000* $6,000*
* Once the family deductible is met, all family members will be considered having met their deductible for the remainder of the calendar year. No
one family member may contribute more than the individual deductible amount to the family deductible.
Coinsurance
0% 30% 20% 40%
Out-of-Pocket Maximum Includes Deductible Includes Deductible Includes Deductible Includes Deductible
Individual $2,200 $10,000 $3,500 $7,000
Family $4,400 $20,000 $7,000* $14,000*
* Once the family maximum out-of-pocket limit is met, all family members will be considered having met their maximum out-of-pocket limit for
the remainder of the calendar year. No one family member may contribute more than the individual maximum out-of-pocket limit amount to
the family maximum out-of-pocket limit. The out-of-pocket limit includes all copays, deductibles, and coinsurance.
Physician Oice Visits
Covered 100%
Primary Care 30% after deductible $40 copay 30% after deductible
after deductible
Covered 100%
Specialist 30% after deductible $65 copay 30% after deductible
after deductible
Covered 100% Covered 100% $50 copay; $50 copay;
Urgent Care
after deductible after deductible deductible waived deductible waived
Non-Urgent Use of Covered 100% Covered 100% $50 copay; $50 copay;
Urgent Care Provider after deductible after deductible deductible waived deductible waived
Wellness/Preventive
Routine Adult Physical Exams/ Covered 100%, 30% after deductible $0 copay; 30% after deductible
Immunizations no deductible deductible waived
Well Child Exams/Immunizations Covered 100%, Covered 100%, $0 copay; $0 copay;
(birth-age 4) no deductible no deductible deductible waived deductible waived
Well Child Exams/Immunizations Covered 100%, 30% after deductible $0 copay; 30% after deductible
(age 5 and older) no deductible deductible waived
Covered 100%, $0 copay;
Routine Gynecological Exams 30% after deductible 30% after deductible
no deductible deductible waived
Routine Mammograms Covered 100%, 30% after deductible $0 copay; 40% after deductible
Based on place of service no deductible deductible waived
Women’s Services Covered 100%, Coverage varies based $0 copay; 40% after deductible
(Family Planning) no deductible on place of service deductible waived
Routine Digital Rectal Exam/ Covered 100%, Coverage varies based $0 copay; Coverage varies based
Prostate-Speciic Antigen Test no deductible on place of service deductible waived on place of service
Routine or Preventive Colorectal Covered 100%, 30% after deductible $0 copay; 40% after deductible
Cancer Screening no deductible deductible waived
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Cigna Plan 1—HDHP/HSA Cigna Plan 2—PPO
In-Network Out-of-Network In-Network Out-of-Network
Lifetime Maximum Unlimited Unlimited Unlimited Unlimited
Calendar Year Deductible
Individual $2,200 $4,500 $1,500 $3,000
Family $4,400 $9,000 $3,000* $6,000*
* Once the family deductible is met, all family members will be considered having met their deductible for the remainder of the calendar year. No
one family member may contribute more than the individual deductible amount to the family deductible.
Coinsurance
0% 30% 20% 40%
Out-of-Pocket Maximum Includes Deductible Includes Deductible Includes Deductible Includes Deductible
Individual $2,200 $10,000 $3,500 $7,000
Family $4,400 $20,000 $7,000* $14,000*
* Once the family maximum out-of-pocket limit is met, all family members will be considered having met their maximum out-of-pocket limit for
the remainder of the calendar year. No one family member may contribute more than the individual maximum out-of-pocket limit amount to
the family maximum out-of-pocket limit. The out-of-pocket limit includes all copays, deductibles, and coinsurance.
Physician Oice Visits
Covered 100%
Primary Care 30% after deductible $40 copay 30% after deductible
after deductible
Covered 100%
Specialist 30% after deductible $65 copay 30% after deductible
after deductible
Covered 100% Covered 100% $50 copay; $50 copay;
Urgent Care
after deductible after deductible deductible waived deductible waived
Non-Urgent Use of Covered 100% Covered 100% $50 copay; $50 copay;
Urgent Care Provider after deductible after deductible deductible waived deductible waived
Wellness/Preventive
Routine Adult Physical Exams/ Covered 100%, 30% after deductible $0 copay; 30% after deductible
Immunizations no deductible deductible waived
Well Child Exams/Immunizations Covered 100%, Covered 100%, $0 copay; $0 copay;
(birth-age 4) no deductible no deductible deductible waived deductible waived
Well Child Exams/Immunizations Covered 100%, 30% after deductible $0 copay; 30% after deductible
(age 5 and older) no deductible deductible waived
Covered 100%, $0 copay;
Routine Gynecological Exams 30% after deductible 30% after deductible
no deductible deductible waived
Routine Mammograms Covered 100%, 30% after deductible $0 copay; 40% after deductible
Based on place of service no deductible deductible waived
Women’s Services Covered 100%, Coverage varies based $0 copay; 40% after deductible
(Family Planning) no deductible on place of service deductible waived
Routine Digital Rectal Exam/ Covered 100%, Coverage varies based $0 copay; Coverage varies based
Prostate-Speciic Antigen Test no deductible on place of service deductible waived on place of service
Routine or Preventive Colorectal Covered 100%, 30% after deductible $0 copay; 40% after deductible
Cancer Screening no deductible deductible waived
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