Page 21 - Benefits Summary 2018-2019 b_Neat

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SUMMARY OF BENEFITS Cigna Health and Life Insurance Co.

Hercules Real Estate Services, Inc.
Open Access Plus- High Plan
Effective Date: 11/1/2018

General Services In-Network Out-of-Network
After the plan deductible is met,
Physician office visit – Primary Care Physician You pay $30 per visit copay,
(PCP) then plan pays 100% You pay 30%
Plan pays 70%
After the plan deductible is met,
You pay $50 per visit copay,
Physician Office Visit – Specialist You pay 30%
then plan pays 100%
Plan pays 70%
Cigna Telehealth Connection Services
 Includes charges for the delivery of medical and
health-related consultations via secure You pay $30 per visit copay,
telecommunications technologies, telephones then plan pays 100% Not Covered
and internet only when delivered by contracted
medical telehealth providers (see details on
myCigna.com)
After the plan deductible is met,
Urgent care visit You pay $100 per visit copay, You pay 30%
 All services including Lab & X-ray then plan pays 100%
Plan pays 70%
After the plan deductible is met,
Plan pays 100%, no copay, no
Preventive Care You pay 30%
deductible
Plan pays 70%
After the plan deductible is met,
Plan pays 100%, no copay, no
Preventive Services You pay 30%
deductible
Plan pays 70%
After the plan deductible is met,
Plan pays 100%, no copay, no
Immunizations You pay 30%
deductible
Plan pays 70%
After the plan deductible is met, After the plan deductible is met,
Coinsurance You pay 0% You pay 30%
Plan pays 100% Plan pays 70%
Plan year deductible
 Benefits for an individual within a family are
paid once the individual deductible has been
met. Individual: $400 Individual: $800
 In-network and out-of-network expenses cross Family: $800 Family: $1,600
accumulate.
 Copays always apply before plan deductible
and coinsurance.
Out-of-pocket annual maximum
 Medical copays apply towards the out-of-pocket
maximums
 Medical deductibles apply towards the out-of-
pocket maximums Individual: $2,500 Individual: $3,750
 Expenses do cross accumulate between in- Family: $5,000 Family: $7,500
network and out-of-network out-of-pocket
maximums
 Per admission deductible applies towards the
out-of-pocket maximum
11/1/2018
ASO
Open Access Plus - OAP High 11-2018 - 7899546. Version# 12

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