Page 7 - Success Academy | 21-22 Benefits Summary
P. 7

 Copay Plus Plan
The Copay Plus Plan is a Preferred Provider Organization (PPO) plan that allows you to choose your providers from within Cigna’s Open Access Plus network or outside it.
For in-network providers, there are three types of payments for medical services with this plan: your copay at the doctor’s office, your deductible, and your coinsurance. The most common copays are $15 per visit for a primary care doctor and $30 for a specialist. The deductible is the amount that you’ll need to pay for inpatient hospitalization and outpatient professional services before splitting the cost with Success, $500 (Employee Only) / $1,000 (Employee + Dependents). After you satisfy your annual deductible, Success will cover 90% of your medical costs and you’ll be responsible for the remaining 10% until you reach your annual maximum of $2,000 (Employee Only) / $4,000 (Employee + Dependents).
Your costs for seeing an out-of-network provider will be higher: First you must pay the out-of-network deductible of $2,500 (Employee Only) / $5,000 (Employee + Dependents). Thereafter, you’ll pay 30% and Success will cover 70% of the costs (up to 300% of what Medicare deems reasonable; if the fee exceeds this amount, you are responsible) until you reach your annual maximum of $5,000 (Employee Only) / $10,000 (Employee + Dependents).
Visit for a listing of network providers in the Cigna OAP Network.
• Comprehensive medical coverage.
• Flexibility:coverageforbothin-networkand out-of-network providers.
• Setprescriptioncosts:upto$15forgeneric, $30 for preferred, and $60 for nonpreferred.
• ThereisnoHSAbankaccount,sothereisno future value from unspent HSA funds. Employ- ees are unable to set aside pre-tax contributions toward an HSA account, and are ineligible for quarterly HSA contributions from SA.
• Deductible:In-Networkmustmeetdeductibleof $500 Employee Only before coinsurance begins for inpatient hospitalization and outpatient professional services.
• Coinsurance: SA employees must pay 10% for in-network care and 30% for out-of-network care after meeting deductible.

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