Page 8 - KIPP NYC 2022 Benfits Summary

Cigna Medical and Prescription Drug Plan Summary
CIGNA EPO PLAN
CIGNA PPO PLAN
In-Network Only
In-Network
Out-of-Network
Deductible (individual/family)
Coinsurance (plan pays)
Out-of-Pocket Maximum (includes deductible)
Rx Deductible
Rx Deductible Resets
Retail Prescription Drug Copays (Tiers 1, 2 & 3) (30 day supply)
Mail Order Prescription Drug Copays (Tiers 1, 2 & 3)
(90 day supply)
Preventive Care
Office Visits — Primary
Mental Health Outpatient care
Office Visits — Specialist
Telemedicine
Lab & Radiology
Chiropractic Care
Emergency Room
Urgent Care
Hospitalization
Outpatient Surgery
Skilled Nursing Facility
Hospice Care
Home Healthcare
Short-Term Rehab
Infertility
Mental Health Inpatient care
Out-of-Network Reimbursement Level
$750/$1,500
N/A
$5,080/$12,700
All services accumulate to the Out-of-Pocket Maximum
N/A
N/A
$10/$40/$60
$20/$80/$120
Covered 100%
$30 copay
$30 copay
$50 copay
$30 copay
Deductible applies
$50 copay
No daily limit; Subjectto Medical Necessity
$200 copay; waived if admitted
$30 copay
$500 copay per admission then deductible applies ($1,250 calendar year copay maximum)
$250 copay then deductible applies
Deductible applies 60 days per plan year
Deductible applies Unlimited visits per calendar year
Deductible applies Unlimited visits per calendar year
$30 copay
60 PT visits per calendar year, 60 visits all other therapies combined
Cost & reimbursement vary based on the facility in which service is performed.
$500 copay per admission then deductible applies ($1,250 calendar year copay maximum)
N/A
$750/$1,500
N/A
$5,080/$12,700
All services accumulate to the Out-of-Pocket Maximum
$50 per individual / $100 per family Applies to Tiers 2 & 3 only
$2,000/$5,000
70%
$9,500/$23,750
All services accumulate to the Out-of-Pocket Maximum
N/A
Not covered
Not covered
Deductible & Coinsurance
Deductible & Coinsurance
Deductible & Coinsurance
Deductible & Coinsurance
Not covered
Deductible & Coinsurance
Deductible & Coinsurance No daily limit; Subject to Medical Necessity
$200 copay; waived if admitted
$30 copay
Deductible & Coinsurance
Deductible & Coinsurance
Deductible & Coinsurance 60 days per plan year
Not covered
70% coinsurance Unlimited visits per calendar year
Deductible & Coinsurance
Deductible & Coinsurance
Deductible & Coinsurance
$10/$40/$60
$20/$80/$120
Covered 100%
$30 copay
$30 copay
$50 copay
$30 copay
Deductible applies
$50 copay
No daily limit; Subjectto Medical Necessity
$200 copay; waived if admitted
$30 copay
$500 copay per admission then deductible applies ($1,250 calendar year copay maximum)
$250 copay then deductible applies
Deductible applies 60 days per plan year
Deductible applies Unlimited visits per calendar year
Deductible applies Unlimited visits per calendar year
$30 copay
60 PT visits per calendar year, 60 visits all other therapies combined
Cost & reimbursement vary based on the facility in which service is performed.
$500 copay per admission then deductible applies ($1,250 calendar year copay maximum)
Every January 1
8 KIPP NYC PUBLIC SCHOOLS
N/A
150% of Medicare