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US Mainland —Medical Plan Details
This plan is only available to U.S. mainland employees.
Cigna Open Access Plus Cigna Open Access Plus Cigna Open Access Plus Cigna Open Access Plus Cigna Open Access Plus
Base Buy-Up Choice HDHP 1 HDHP 2
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
Embedded* Embedded* Embedded* Embedded* Embedded*
Individual $2,000 $4,000 $1,500 $3,000 $750 $2,250 $3,500 $7,000 $6,350 $10,000
Family $4,000 $12,000 $3,000 $9,000 $2,250 $6,750 $7,000 $14,000 $12,700 $20,000
Out-of-Pocket Maximum (includes deductible)
Individual $6,350 $16,000 $5,000 $8,000 $2,500 $8,000 $5,950 $10,000 $6,350 $15,000
Family $12,700 $48,000 $10,000 $24,000 $7,500 $24,000 $11,900 $20,000 $12,700 $15,000
Physician Office Visits
Preventive Care Covered at 100% 50% coinsurance Covered at 100% 30% coinsurance Covered at 100% 30% coinsurance Covered at 100% 40% coinsurance Covered at 100% 50% coinsurance
Primary Care Visit $35 copay 50% coinsurance $25 copay 30% coinsurance $25 copay 30% coinsurance 20% coinsurance 40% coinsurance $25 copay 50% coinsurance
Specialist Visit $50 copay 50% coinsurance $50 copay 30% coinsurance $40 copay 30% coinsurance 20% coinsurance 40% coinsurance Deductible, then 50% coinsurance
0% coinsurance
Telemedicine $35 copay Not covered $25 copay Not covered $25 copay Not covered 20% coinsurance Not covered $25 copay Not covered
Urgent Care $75 copay 50% coinsurance $75 copay 30% coinsurance $75 copay 30% coinsurance 20% coinsurance 40% coinsurance Deductible, then 50% coinsurance
0% coinsurance
Hospital Services
Inpatient 30% coinsurance 50% coinsurance 10% coinsurance 30% coinsurance 10% coinsurance 30% coinsurance 20% coinsurance 40% coinsurance Deductible, then 50% coinsurance
0% coinsurance
Outpatient 30% coinsurance 50% coinsurance 10% coinsurance 30% coinsurance 10% coinsurance 30% coinsurance 20% coinsurance 40% coinsurance Deductible, then 50% coinsurance
0% coinsurance
Emergency Room $250 copay $250 copay $250 copay $250 copay $250 copay $250 copay 20% coinsurance 40% coinsurance Deductible, then 50% coinsurance
0% coinsurance
Prescription Drugs
Please note: for the HDHP 1 qualified plan, all non-preventive, non-generic prescription drug expenses are subject to the Drugs on Cigna's Preventive Generic
medical deductible . Once you meet your deductible, copays, or coinsurance will apply . drug list are covered at 100%, no
deductible .
Retail (per 30-day supply)
Generic* $10 copay $10 copay $10 copay Deductible, then $10 copay
$10 copay
Preferred Brand $35 copay $35 copay $35 copay Deductible, then $35 copay
Formulary $35 copay
Non-Preferred Brand $60 copay $60 copay $60 copay Deductible, then $60 copay
Formulary $60 copay
Specialty 25% up to a maximum 25% up to a maximum 25% up to a Deductible, then 25% up to a
of $250 of $250 maximum of $250 25% up to a maximum of $250
maximum of $250
Mail Order — Retail and Home Delivery (per 90-day supply)
Generic* $20 copay $20 copay $20 copay Deductible, then $20 copay
$20 copay
Preferred Brand $70 copay $70 copay $70 copay Deductible, then $70 copay
Formulary $70 copay
Non-Preferred Brand $120 copay $120 copay $120 copay Deductible, then $120 copay
Formulary $120 copay
* If you select a brand name drug when a generic equivalent is available, the plan will only pay the cost of the generic drug unless This is a high level summary of your benefit coverage . Full coverage details are available in your summary plan description (SPD) . In
your physician indicates “Dispense as Written” on the prescription . the event there is a discrepancy between what is reflected in this guide and what is communicated in your SPD, the terms of your
SPD will prevail .
Dawson 11
This plan is only available to U.S. mainland employees.
Cigna Open Access Plus Cigna Open Access Plus Cigna Open Access Plus Cigna Open Access Plus Cigna Open Access Plus
Base Buy-Up Choice HDHP 1 HDHP 2
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
Embedded* Embedded* Embedded* Embedded* Embedded*
Individual $2,000 $4,000 $1,500 $3,000 $750 $2,250 $3,500 $7,000 $6,350 $10,000
Family $4,000 $12,000 $3,000 $9,000 $2,250 $6,750 $7,000 $14,000 $12,700 $20,000
Out-of-Pocket Maximum (includes deductible)
Individual $6,350 $16,000 $5,000 $8,000 $2,500 $8,000 $5,950 $10,000 $6,350 $15,000
Family $12,700 $48,000 $10,000 $24,000 $7,500 $24,000 $11,900 $20,000 $12,700 $15,000
Physician Office Visits
Preventive Care Covered at 100% 50% coinsurance Covered at 100% 30% coinsurance Covered at 100% 30% coinsurance Covered at 100% 40% coinsurance Covered at 100% 50% coinsurance
Primary Care Visit $35 copay 50% coinsurance $25 copay 30% coinsurance $25 copay 30% coinsurance 20% coinsurance 40% coinsurance $25 copay 50% coinsurance
Specialist Visit $50 copay 50% coinsurance $50 copay 30% coinsurance $40 copay 30% coinsurance 20% coinsurance 40% coinsurance Deductible, then 50% coinsurance
0% coinsurance
Telemedicine $35 copay Not covered $25 copay Not covered $25 copay Not covered 20% coinsurance Not covered $25 copay Not covered
Urgent Care $75 copay 50% coinsurance $75 copay 30% coinsurance $75 copay 30% coinsurance 20% coinsurance 40% coinsurance Deductible, then 50% coinsurance
0% coinsurance
Hospital Services
Inpatient 30% coinsurance 50% coinsurance 10% coinsurance 30% coinsurance 10% coinsurance 30% coinsurance 20% coinsurance 40% coinsurance Deductible, then 50% coinsurance
0% coinsurance
Outpatient 30% coinsurance 50% coinsurance 10% coinsurance 30% coinsurance 10% coinsurance 30% coinsurance 20% coinsurance 40% coinsurance Deductible, then 50% coinsurance
0% coinsurance
Emergency Room $250 copay $250 copay $250 copay $250 copay $250 copay $250 copay 20% coinsurance 40% coinsurance Deductible, then 50% coinsurance
0% coinsurance
Prescription Drugs
Please note: for the HDHP 1 qualified plan, all non-preventive, non-generic prescription drug expenses are subject to the Drugs on Cigna's Preventive Generic
medical deductible . Once you meet your deductible, copays, or coinsurance will apply . drug list are covered at 100%, no
deductible .
Retail (per 30-day supply)
Generic* $10 copay $10 copay $10 copay Deductible, then $10 copay
$10 copay
Preferred Brand $35 copay $35 copay $35 copay Deductible, then $35 copay
Formulary $35 copay
Non-Preferred Brand $60 copay $60 copay $60 copay Deductible, then $60 copay
Formulary $60 copay
Specialty 25% up to a maximum 25% up to a maximum 25% up to a Deductible, then 25% up to a
of $250 of $250 maximum of $250 25% up to a maximum of $250
maximum of $250
Mail Order — Retail and Home Delivery (per 90-day supply)
Generic* $20 copay $20 copay $20 copay Deductible, then $20 copay
$20 copay
Preferred Brand $70 copay $70 copay $70 copay Deductible, then $70 copay
Formulary $70 copay
Non-Preferred Brand $120 copay $120 copay $120 copay Deductible, then $120 copay
Formulary $120 copay
* If you select a brand name drug when a generic equivalent is available, the plan will only pay the cost of the generic drug unless This is a high level summary of your benefit coverage . Full coverage details are available in your summary plan description (SPD) . In
your physician indicates “Dispense as Written” on the prescription . the event there is a discrepancy between what is reflected in this guide and what is communicated in your SPD, the terms of your
SPD will prevail .
Dawson 11
