Page 14 - Harvard Maintenance Executive 2022 Benefits Guide

Calendar Year 2022
Benefits Enrollment

Cigna Open Access Plus (PPO) Plan

Plan Highlights In-Network Out-of-Network*
Annual Calendar Year Deductible
Individual $0 $500
Family $0 $1,250
Maximum Calendar Year Out-of-Pocket
Individual $500 $1,500
Family $1,500 $4,500
Professional Services
Primary Care Physician (PCP) Oice Visit $15 copay 20% coinsurance after deductible
Specialist Oice Visits $30 copay 20% coinsurance after deductible
Preventative Care Exam Covered 100% 20% coinsurance after deductible
Well-Baby Care Covered 100% Covered 100%
Diagnostic Lab and X-Ray (after deductible) Lab: Covered 100% Lab: 20% coinsurance after deductible
X-ray: Covered 100% X-ray: 20% coinsurance after deductible
Complex Diagnostics (MRI/CT scan) Covered 100% 20% coinsurance after deductible
(after deductible)
Chiropractic $30 copay 20% coinsurance after deductible
Therapy, Including Physical, Occupational, and $30 copay 20% coinsurance after deductible
Speech (30 visits per calendar year combined)
Hospital Services (after deductible)
Inpatient Covered 100% 20% coinsurance after deductible
Outpatient Services Covered 100% 20% coinsurance after deductible
Emergency Use of Ambulance Covered 100% Covered 100%
Emergency Room (deductible waived) $200 copay $200 copay
Urgent Care (deductible waived) $50 copay 20% coinsurance after deductible
Maternity Care (after deductible)
Inpatient Hospital Services Covered 100% 20% coinsurance after deductible
Mental Health Services (after deductible)
Inpatient Covered 100% 20% coinsurance after deductible
Mental Health Oice Visits $15 copay 20% coinsurance after deductible
Recovery Services (after deductible)
Home Healthcare (60 visits per calendar year) Covered 100% 20% coinsurance after deductible
Skilled Nursing Care (60 days per calendar year) Covered 100% 20% coinsurance after deductible
Prescription Drugs (30-day supply)
Preferred Generic Drugs (Tier 1) $10 copay $10 copay + 20% after deductible
Preferred Brand-Name Drugs (Tier 2) $20 copay $20 copay + 20% after deductible
Non-Preferred (Tier 3) $40 copay $40 copay + 20% after deductible
* All out-of-network services are after the plan deductible unless otherwise stated .

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