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Medical and Pharmacy Coverage

2500 OAP
Medical Plan Provisions In-Network Out-of-Network

Annual Deductible (Individual/Family) $2,500/$5,000 $4,000/$8,000
Deductible- Aggregate or Embedded Aggregate
Out-of-Pocket Maximum (Includes Deductible) $4,500/$9,000 $8,000/$16,000

Coinsurance 80% 60%
Preventive Care Covered at 100% 60%
Primary Care Provider Office Visit 80%* 60%

Specialist Office Visit 80%* 60%
Diagnostic X-ray/Labs (Routine) 80%* 60%
Complex Imaging Services (MRI) 80%* 60%

Inpatient Hospital Services 80%* 60%
Outpatient Surgery 80%* 60%
Urgent Care 80%* 60%

Emergency Room 80%*
Retail Pharmacy (up to a 30-day supply)

Generic $10 copay*
Brand Preferred $25 copay*
Brand Non-Preferred $40 copay*
Mail Order Pharmacy (90-day supply)

Generic $20 copay*
Brand Preferred $50 copay*

Brand Non-Preferred $80 copay*
*After deductible

Medical Plan ID Cards
All Cigna ID cards are electronic. Once your coverage is active, you can register on mycigna.com or through the
Cigna app with your SSN, date of birth, and ZIP code on file to view your ID card. You can also request a physical ID
card online, if you prefer.

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