Page 7 - 2022 DPR Construction Benefit Guide_Administrative Employees

CIGNA CIGNA OPEN
HIGH DEDUCTIBLE HEALTH PLAN ACCESS PLUS PLAN KAISER PLAN
(CA ONLY)
(HDHP) (OAP)
IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK IN-NETWORK
CALENDAR YEAR DEDUCTIBLE
Individual/Family $1,750 / $3,500 $3,000 / $6,000 $500 / $1,500 $1,000 / $3,000 $0
CALENDAR YEAR OUT-OF-POCKET MAXIMUM (INCLUDES DEDUCTIBLE)
Individual/Family $3,000 / $6,000 $6,000 / $12,000 $2,500 / $5,000 $6,000 / $12,000 $1,500 / $3,000
EMPLOYER HEALTH SAVINGS ACCOUNT FUNDING (HSA)
Individual/Family $750 / $1,500 N/A N/A
YOU PAY YOU PAY YOU PAY
Preventive Care No Charge Not Covered No Charge 30%* No Charge
Office Visit
(Primary Care 10%* 30%* $25 / $40 30%* $20 / $20
Physician/
Specialist)
Urgent Care 10%* $50 + 10%* $20

Emergency Room 10%* $200 + 10%* $100
$50 per admit, up to
$250 maximum
Inpatient Stay 10%* 30%* $250 + 30%* $100
per calendar year,
+ 10%*
Outpatient 10%* 30%* $50 + 10%* $50 + 30%* $20
Surgery
PHARMACY
RETAIL RX
Generic $10* $10 $15
Preferred Brand $40* $40 $30
Non-Preferred $60* Not Covered $60 30% $30
Brand
Specialty 20% up to $150* 20% up to $150 20% up to $200
MAIL ORDER RX (UP TO 90-DAY SUPPLY)
Generic $20* $20 $30
Preferred Brand $80* $80 $60
Non-Preferred $120* Not Covered $120 Not Covered $60
Brand
Specialty 20% up to $150* 20% up to $150 20% up to $200
* After deductible

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