Page 4 - Benefits Summary/New Hire Enrollment Guide

Cigna
HRA Open Access Plus
National Network - no referral
Cigna Benefit Highlights

Please note:
• Saco River Medical Group: Services will be billed as an office copay

Deductible - In-Network $5,000/$10,000

Annual Out-of-Pocket Maximum (Med and Rx combined) $6,500/$13,000

Coinsurance Out-of-Network N/A

Inpatient - Physician & Hospital Deductible, then No Charge

Outpatient Day Surgery Deductible, then No Charge

Annual Preventative Services No Charge

$25 Copay PCP or Specialist
Office Visit - Primary Care/Specialist
(Also $25 copay for Office Surgery with PCP/Specialist)

Labs No Charge

X-Rays Covered in Full
X-rays and Advanced Radiology Advanced Radiology (MRI, CT Scan, etc.):
Deductible then No Charge

Emergency Room Care: All services rendered apply
Deductible, then No Charge
to ER benefit including lab and x-ray

Convenience Care Clinic: $25 Copay
Urgent Care Services Urgent Care Clinic: $50 Copay
Hospital Urgent Care Clinic: Deductible

Telehealth Connection $25 Copay

Acupuncture (20 days per plan year) $25 Copay

Hearing Aids: Maximum of 2 devices (1 per ear)
No Charge
every 36 months, includes testing and fitting

Chiropractic (12 days per plan year) $25 Copay

Therapies: Physical/Occupational/Speech
$25 Copay
(60 days per plan year)
Cigna Prescription Plan

Retail Prescription Drug (30-day supply) $5/$25/$45
Retail Prescription Drug (90-day supply) $15/$75/$135
Mail Order Prescription Drug (90 day supply) $10/$50/$90