Page 6 - TVS 2022 Benefits Guide

Cigna Plan 1—HDHP/HSA Cigna Plan 2—PPO
In-Network Out-of-Network In-Network Out-of-Network
Diagnostic Procedures
Outpatient Diagnostic Covered 100% 30% after deductible 20% after deductible 40% after deductible
Laboratory after deductible
Outpatient X-ray (except Covered 100% 30% after deductible 20% after deductible 40% after deductible
complex imaging services) after deductible
20% after deductible; 40% after deductible
outpatient in oice
Covered 100% subject to copay for outpatient; in
MRI, MRA, PET, and CT Scans 30% after deductible oice subject to
after deductible $40 Primary Care deductible payable
Provider/
$65 Specialist at 30%
Hospital Services
Covered 100%
Inpatient after deductible 30% after deductible 20% after deductible 40% after deductible

Covered 100%
Outpatient after deductible 30% after deductible 20% after deductible 40% after deductible

Covered 100%
waived; copay waived waived; copay waived
Emergency Room after deductible Covered 100% after $75 copay; deductible $75 copay; deductible
deductible
if admitted
if admitted
Non-Emergency Care in an Not covered Not covered Not covered Not covered
Emergency Room
Chiropractic Care
$65 copay;
Covered 100%
Chiropractic after deductible 30% after deductible deductible waived 30% after deductible
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
Deductible, then
Preferred Brand covered at 100% 30% after deductible 40% after copay 40% after copay
Non-Preferred Brand

Please refer to your plan documents for more detailed information.

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