Page 7 - 2018 Zumba Employee Benefits Guide

7

Medical Plan

This chart outlines the basic provisions of the Cigna medical plan.

Cigna HRA OAP (Open Access Plan)
Benefit In-Network Out-of-Network
Annual Deductible
(Individual/Family) $2,000/$4,000 $3,500/$7,000
Out-of-Pocket Maximum (includes Deductible)
(Individual/Family) $4,000/$8,000 $6,000/$12,000
Lifetime Maximum Unlimited Unlimited
Preventive Care 100% 30%*

Primary Physician Office Visit $25 co-pay 30%*
Specialist Office Visit $50 co-pay 30%*
X-Ray and Lab (LabCorp & Quest Diagnostic) 100% 30%*

Inpatient Hospital Services 100% after deductible 30%*
Outpatient Hospital Services 100% after deductible 30%*
Urgent Care $75 30%*
Emergency Room Care $400 30%*
Major Radiology (MRI, CAT scan, etc.) $350 30%*

Prescription Drugs (30 day supply)
Tier 1 - Generic $10
Tier 2 - Preferred Brand $30
50% co-insurance
Tier 3 - Non-Preferred Brand $70
Tier 4 - Specialty Drugs 20% co-insurance
Mail Order Pharmacy 3x’s co-pay Not Covered
*After deductible is met
Note: This is a summary only of your coverage. In-network services are based on negotiated charges; out-of-network services are based on reasonable and
customary (R&C) charges.

Home delivery service is safe and reliable. It also offers convenience and savings, 24/7 phone access to pharmacists,
and helpful reminders.

Preventive Health Care Services:

• Yearly Physical Checkup
• Yearly OB/GYN Checkup
• Breast Cancer Screening
• Birth Control Pills
• Flu and Measles Shot
• Colonoscopy
• Preventive Exams