Page 6 - 2018 Endeavor Schools Benefit Guide

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Cigna Medical Plan Cigna Gold Plan

Summary of Services In-Network Out-of-Network

Calendar Year Deductible
Individual $1,500 $3,000
Family $3,000 $6,000
Out-of-Pocket Maximum
Individual $4,500 $13,000
Family $9,000 $26,000

Member Coinsurance 0% 30%

Office Visits
Physician $35 copay 30% after deductible
Specialist $60 copay 30% after deductible

Preventative Care Covered 100% Covered 100%

Diagnostic Lab & X-Ray $35 copay 30% after deductible

Major Diagnostic Services (MRI, PET, $100 copay 30% after deductible
CT Scan)

Emergency Room $300 copay $300 copay

Urgent Care $75 copay 30% after deductible

Hospitalization (In-patient) $100 per admission 30% after deductible

Outpatient Surgery 0% after deductible 30% after deductible

Prescription Drug Benefits
Tier 1 - Preferred Generic $10 copay
Tier 2 - Preferred Brand $35 copay Subject to deductible and 50%
Tier 3 - Non-Preferred Brand $60 copay
Tier 4 - Specialty Drugs 30% up to $250 max copay

Prescription Drug Benefits 2.5x Retail Subject to deductible and 50%
Mail Order - 90 Day Supply

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.