Page 5 - AB Mauri 2022 Benefits Guide MOIL
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2022 Benefits Enrollment
Cigna Medical and Prescription Plans
High Deductible Health Plan/
HMO OAP
HSA
Calendar Year Deductible (Embedded)
Individual $0 $500 $3,000
Family $0 $1,000 $6,000
Out-of-Pocket Maximum
Individual $3,000 $1,500 $6,000
Family $6,000 $3,000 $12,000
Hospital Services
Inpatient $250 copay per admission 20% after deductible 100% covered after deductible
Outpatient $125 copay per visit 20% after deductible 100% covered after deductible
Emergency Room $150 copay 20% after deductible 100% covered after deductible
Oice Visits
Preventive Care 100% covered 100% covered 100% covered
20% after deductible 100% covered after deductible
Virtual Visit $20 copay
Visit cost $55 Visit cost $55
Primary Care $20 copay 20% after deductible 100% covered after deductible
Specialist $30 copay 20% after deductible 100% covered after deductible
Chiropractic Care $30 copay 20% after deductible 100% covered after deductible
Urgent Care $50 copay 20% after deductible 100% covered after deductible
Prescription Drugs
Retail—30 Day Supply Preventive Rx 100% covered
Tier 1 $15 copay $15 copay $10 copay after deductible
Tier 2 $30 copay $30 copay $30 copay after deductible
Tier 3 $50 copay $50 copay $60 copay after deductible
Mail Order—90 Day Supply
Tier 1 $45 copay $30 copay $30 copay after deductible
Tier 2 $90 copay $60 copay $90 copay after deductible
Tier 3 $150 copay $100 copay $180 copay after deductible
Please note: The above chart is a summary of the medical plan beneits for in-network coverage. The OAP and HDHP ofers out-of-network beneits;
however, beneits are reduced when care is provided out-of-network. The chart above is a brief summary of your medical beneits and does not
include all the details about beneit plan features and rules. For details and the terms of your medical and pharmacy plan beneits, refer to your Plan
document. If there are any inconsistencies between this document and the oicial Plan document, the Plan documents will prevail.
If you reside in Texas, Tennessee, or California, some of the HMO beneits shown in the chart above may difer due to state requirements.
The preventive Rx list for the HDHP/HSA plan can be obtained from Human Resources.
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Cigna Medical and Prescription Plans
High Deductible Health Plan/
HMO OAP
HSA
Calendar Year Deductible (Embedded)
Individual $0 $500 $3,000
Family $0 $1,000 $6,000
Out-of-Pocket Maximum
Individual $3,000 $1,500 $6,000
Family $6,000 $3,000 $12,000
Hospital Services
Inpatient $250 copay per admission 20% after deductible 100% covered after deductible
Outpatient $125 copay per visit 20% after deductible 100% covered after deductible
Emergency Room $150 copay 20% after deductible 100% covered after deductible
Oice Visits
Preventive Care 100% covered 100% covered 100% covered
20% after deductible 100% covered after deductible
Virtual Visit $20 copay
Visit cost $55 Visit cost $55
Primary Care $20 copay 20% after deductible 100% covered after deductible
Specialist $30 copay 20% after deductible 100% covered after deductible
Chiropractic Care $30 copay 20% after deductible 100% covered after deductible
Urgent Care $50 copay 20% after deductible 100% covered after deductible
Prescription Drugs
Retail—30 Day Supply Preventive Rx 100% covered
Tier 1 $15 copay $15 copay $10 copay after deductible
Tier 2 $30 copay $30 copay $30 copay after deductible
Tier 3 $50 copay $50 copay $60 copay after deductible
Mail Order—90 Day Supply
Tier 1 $45 copay $30 copay $30 copay after deductible
Tier 2 $90 copay $60 copay $90 copay after deductible
Tier 3 $150 copay $100 copay $180 copay after deductible
Please note: The above chart is a summary of the medical plan beneits for in-network coverage. The OAP and HDHP ofers out-of-network beneits;
however, beneits are reduced when care is provided out-of-network. The chart above is a brief summary of your medical beneits and does not
include all the details about beneit plan features and rules. For details and the terms of your medical and pharmacy plan beneits, refer to your Plan
document. If there are any inconsistencies between this document and the oicial Plan document, the Plan documents will prevail.
If you reside in Texas, Tennessee, or California, some of the HMO beneits shown in the chart above may difer due to state requirements.
The preventive Rx list for the HDHP/HSA plan can be obtained from Human Resources.
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