Page 7 - 2022 DPR Construction Benefit Guide_Craft Employees

CIGNA OPEN CIGNA OPEN
ACCESS PLUS PLAN 90/70 ACCESS PLUS PLAN 80/60
IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK
CALENDAR YEAR DEDUCTIBLE
Individual/Family $500 / $1,500 $1,000 / $3,000 $750/$1,500 $750/$1,500
CALENDAR YEAR OUT-OF-POCKET MAXIMUM (INCLUDES DEDUCTIBLE)
Individual/Family $2,500 / $5,000 $6,000 / $12,000 $3,500/$7,000 $5,500/$11,000
YOU PAY YOU PAY
Preventive Care No Charge 30%* No Charge 40%*
Office Visit (Primary
Care Physician/ $25 / $40 30%* $25/$40 40%*
Specialist)
Urgent Care $50 + 10%* $100*

Emergency Room $200 + 10%* $200*

$50 per admit, up to
Inpatient Stay $250 maximum per $250 + 30%* $50 per admit + 20%* $250 + 40%*
calendar year, + 10%*
Outpatient Surgery $50 + 10%* $50 + 30%* $50 + 20%* $50 + 40%*
PHARMACY
RETAIL RX
Generic $10 $10
Preferred Brand $40 30% $40 20%
Non-Preferred Brand $60 $60
Specialty 20% up to $150 20% up to $150
MAIL ORDER RX (UP TO 90-DAY SUPPLY)
Generic $20 $20
Preferred Brand $80 Not Covered $80 Not Covered
Non-Preferred Brand $120 $120
Specialty 20% up to $150 20% up to $150
* After deductible
More detailed medical benefit information available on HR Connection.

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