Page 3 - Benefits Summary 2018-2019 b_Neat

HMO

SUMMARY OF BENEFITS Cigna Health and Life Insurance Co.

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

General Services In-Network
Physician office visit – Primary Care Physician You pay $40 per visit copay, then plan pays 100%
(PCP)
Physician Office Visit – Specialist You pay $50 per visit copay, then plan pays 100%
Cigna Telehealth Connection Services
 Includes charges for the delivery of medical and
health-related consultations via secure
telecommunications technologies, telephones You pay $40 per visit copay, then plan pays 100%
and internet only when delivered by contracted
medical telehealth providers (see details on
myCigna.com)
Urgent care visit You pay $100 per visit copay, then plan pays 100%
 All services including Lab & X-ray
Preventive Care Plan pays 100%, no copay, no deductible
Preventive Services Plan pays 100%, no copay, no deductible
Immunizations Plan pays 100%, no copay, no deductible
After the plan deductible is met,
Coinsurance You pay 30%
Plan pays 70%
Plan year deductible
 Benefits for an individual within a family are
paid once the individual deductible has been Individual: $750
met. Family: $1,500
 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- Individual: $4,000
Family: $8,000
pocket maximums
 Per admission deductible applies towards the
out-of-pocket maximum
Unlimited
Lifetime maximum
Per individual
Emergency room care You pay $200 per visit copay (waived if admitted),
 All services rendered apply to ER benefit then plan pays 100%
including Lab & X-ray
After the in-network plan deductible is met,
Ambulance You pay 30%
Plan pays 70%
Office surgery – PCP You pay $40 per visit copay, then plan pays 100%
Office surgery – Specialist You pay $50 per visit copay, then plan pays 100%
Other office services – laboratory Covered same as plan’s Physician’s Office Services
Other office services – radiology Covered same as plan’s Physician’s Office Services
Plan pays 100%,
Outpatient lab
no deductible
11/1/2018
ASO
Open Access Plus - OAPin Low 11-2018 - 7899882. Version# 12

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