Page 6 - 2018 Turnberry Associates Guide Boston

Medical Plan

CIGNA Medical Plan CIGNA Open Access Plus

Summary of Services In-Network Benefits Out-of-Network Benefits

Calendar Year Deductible
Individual $0 $1,000
Family $0 $2,000
Includes Medical & Rx Coinsurance & Copays Includes Medical Deductible, Medical & Rx
Out-of-Pocket Maximum Coinsurance & Copays
Individual $3,000 $6,000
Family
$6,000 $12,000
Member Coinsurance 20% 40%

Office Visits
Physician $0 copay 40% coinsurance
Specialist $25 copay 40% coinsurance
Office Visits (Preventive Visits)
Well Child Care Visit $0 40% coinsurance
Routine Adult Physical $0 40% coinsurance
Well Women/GYN Exams $0 40% coinsurance
Mammogram (Age Limitations) $0 $0
Colonoscopy (Age Limitations) $0 $0
Diagnostic Lab & X-Ray $0 40% after deductible
Independent Testing Facility

Major Diagnostic Services (MRI, PET, CT
Scan) 20% 40% after deductible
Independent Testing Facility

Emergency Room $200 copay $200 copay

Urgent Care $35 copay 40% after deductible

Hospitalization (In-patient) 20% 40% after deductible

Outpatient Surgery 20% 40% after deductible

Prescription Drug Benefits
Retail
Tier 1 - Preferred Generic $5 50% coinsurance
Tier 2 - Preferred Brand $10
Tier 3 - Non-Preferred Brand $20
Prescription Drug Benefits
Mail Order - 90 Day Supply
Tier 1 - Preferred Generic $10 50% coinsurance
Tier 2 - Preferred Brand & Specialty $20
Tier 3 - Non-Preferred Brand & Specialty $40
Prescription Drug Benefits Home Delivery
30 Day Supply Not Covered
Specialty Drugs $20

Note: This is a summary of your coverage only. Please refer to your summary plan description for the full scope of coverage. In-network services are based on negotiated charges;
out-of-network services are based on reasonable and customary (R&C) charges.
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