Page 5 - Kirstie Test BenSum

Cigna
HRA Open Access Plus
National Network - no referral
Cigna Benefit Highlights • Saco River Medical Group: Services will be billed as an office copay
Annual Out-of-Pocket Maximum (Med and Rx combined) Coinsurance Out-of-Network
Inpatient - Physician & Hospital
Outpatient Day Surgery
Annual Preventative Services
Office Visit - Primary Care/Specialist Labs
Emergency Room Care: All services rendered apply to ER benefit including lab and x-ray
Telehealth Connection
Chiropractic (12 days per plan year)
Therapies: Physical/Occupational/Speech (60 days per plan year)
Cigna Prescription Plan
Retail Prescription Drug (30-day supply)
Retail Prescription Drug (90-day supply)
Please note:
Deductible - In-Network
$5,000/$10,000 $6,500/$13,000 N/A
Deductible, then No Charge
Deductible, then No Charge
No Charge
$25 Copay PCP or Specialist
(Also $25 copay for Office Surgery with PCP/Specialist)
No Charge
X-Rays Covered in Full Advanced Radiology (MRI, CT Scan, etc.): Deductible then No Charge
Deductible, then No Charge
Convenience Care Clinic: $25 Copay Urgent Care Clinic: $50 Copay Hospital Urgent Care Clinic: Deductible
$25 Copay $25 Copay
No Charge $25 Copay $25 Copay
$5/$25/$45
$15/$75/$135
X-rays and Advanced Radiology
Urgent Care Services
Acupuncture (20 days per plan year)
Hearing Aids: Maximum of 2 devices (1 per ear) every 36 months, includes testing and fitting
MailOrderPrescriptionDrug (90daysupply)
$10/$50/$90