Cigna High Deductible with HSA Plan
Medical benefits are provided through Cigna. Consider the physician networks, premiums, and out-of-pocket costs for each plan when making a selection.
Plan details
Carrier
Cigna
Plan Type
HDHP
Has Out Of Network Coverage
Yes
HSA Eligible
Yes
Premiums
| Coverage Tier | SEMI-MONTHLY | BI-WEEKLY | WEEKLY |
|---|---|---|---|
| Employee Only | $75.07 | $69.30 | $34.65 |
| Employee + Spouse* | $190.37 | $175.72 | $87.86 |
| Employee + One Child | $114.88 | $106.04 | $53.02 |
| Employee + Two or More Children | $120.64 | $111.36 | $55.68 |
| Employee + Family* | $193.70 | $178.80 | $89.40 |
Coverage TierEmployee Only
- SEMI-MONTHLY
- $75.07
- BI-WEEKLY
- $69.30
- WEEKLY
- $34.65
Coverage TierEmployee + Spouse*
- SEMI-MONTHLY
- $190.37
- BI-WEEKLY
- $175.72
- WEEKLY
- $87.86
Coverage TierEmployee + One Child
- SEMI-MONTHLY
- $114.88
- BI-WEEKLY
- $106.04
- WEEKLY
- $53.02
Coverage TierEmployee + Two or More Children
- SEMI-MONTHLY
- $120.64
- BI-WEEKLY
- $111.36
- WEEKLY
- $55.68
Coverage TierEmployee + Family*
- SEMI-MONTHLY
- $193.70
- BI-WEEKLY
- $178.80
- WEEKLY
- $89.40
- *Working spouses will be encouraged to seek coverage through their own employers. A $100 monthly spousal surcharge will be assessed if you have elected coverage for your spouse and your spouse is eligible for coverage through his/her employer ($50 deducted twice per month).
Coverage Details
| Service | IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Calendar Year Deductible - Individual | $3,500 | $7,000 |
| Calendar Year Deductible - Family | $7,000 | $14,000 |
| Coinsurance (Employee Pays) | 20%* | 40%* |
| Calendar Year Out-of-Pocket Maximum (Maximum Includes Deductible) - Individual | $7,000 | $14,000 |
| Calendar Year Out-of-Pocket Maximum (Maximum Includes Deductible) - Family | $14,000 | $28,000 |
| Preventive Care | 0% | 40%* |
| Mdlive/Virtual Care | 20%* | Not covered |
| Primary Care | 20%* | 40%* |
| Specialist | 20%* | 40%* |
| Urgent Care | 20%* | 40%* |
| Emergency Room | 20%* | 20%* |
| DIAGNOSTIC TEST (X-ray, Blood Work) | 20%* | 40%* |
| Mental Health – Inpatient | 20%* | 40%* |
| Mental Health – Outpatient | 20%* | 40%* |
ServiceCalendar Year Deductible - Individual
- IN-NETWORK
- $3,500
- OUT-OF-NETWORK
- $7,000
ServiceCalendar Year Deductible - Family
- IN-NETWORK
- $7,000
- OUT-OF-NETWORK
- $14,000
ServiceCoinsurance (Employee Pays)
- IN-NETWORK
- 20%*
- OUT-OF-NETWORK
- 40%*
ServiceCalendar Year Out-of-Pocket Maximum (Maximum Includes Deductible) - Individual
- IN-NETWORK
- $7,000
- OUT-OF-NETWORK
- $14,000
ServiceCalendar Year Out-of-Pocket Maximum (Maximum Includes Deductible) - Family
- IN-NETWORK
- $14,000
- OUT-OF-NETWORK
- $28,000
ServicePreventive Care
- IN-NETWORK
- 0%
- OUT-OF-NETWORK
- 40%*
ServiceMdlive/Virtual Care
- IN-NETWORK
- 20%*
- OUT-OF-NETWORK
- Not covered
ServicePrimary Care
- IN-NETWORK
- 20%*
- OUT-OF-NETWORK
- 40%*
ServiceSpecialist
- IN-NETWORK
- 20%*
- OUT-OF-NETWORK
- 40%*
ServiceUrgent Care
- IN-NETWORK
- 20%*
- OUT-OF-NETWORK
- 40%*
ServiceEmergency Room
- IN-NETWORK
- 20%*
- OUT-OF-NETWORK
- 20%*
ServiceDIAGNOSTIC TEST (X-ray, Blood Work)
- IN-NETWORK
- 20%*
- OUT-OF-NETWORK
- 40%*
ServiceMental Health – Inpatient
- IN-NETWORK
- 20%*
- OUT-OF-NETWORK
- 40%*
ServiceMental Health – Outpatient
- IN-NETWORK
- 20%*
- OUT-OF-NETWORK
- 40%*
- *After deductible
Prescription Drug Coverage
| Tier | IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Calendar Year Deductible - Individual | Combined with Medical | N/A |
| Calendar Year Deductible - Family | Combined with Medical | N/A |
| Retail RX (30-Day Supply) - Preventive Generic Drugs | 0%; No deductible | Not covered |
| Retail RX (30-Day Supply) - Generic Drugs | 20%* | Not covered |
| Retail RX (30-Day Supply) - Preferred Drugs | 20%* | Not covered |
| Retail RX (30-Day Supply) - Non-Preferred Drugs | 20%* | Not covered |
| Mail Order RX (90-Day Supply) - Generic Drugs | 20%* | Not covered |
| Mail Order RX (90-Day Supply) - Preferred Drugs | 20%* | Not covered |
| Mail Order RX (90-Day Supply) - Non-Preferred Drugs | 20%* | Not covered |
| Mail Order RX (90-Day Supply) - Specialty / Specialty Injectibles | 20%* | Not covered |
TierCalendar Year Deductible - Individual
- IN-NETWORK
- Combined with Medical
- OUT-OF-NETWORK
- N/A
TierCalendar Year Deductible - Family
- IN-NETWORK
- Combined with Medical
- OUT-OF-NETWORK
- N/A
TierRetail RX (30-Day Supply) - Preventive Generic Drugs
- IN-NETWORK
- 0%; No deductible
- OUT-OF-NETWORK
- Not covered
TierRetail RX (30-Day Supply) - Generic Drugs
- IN-NETWORK
- 20%*
- OUT-OF-NETWORK
- Not covered
TierRetail RX (30-Day Supply) - Preferred Drugs
- IN-NETWORK
- 20%*
- OUT-OF-NETWORK
- Not covered
TierRetail RX (30-Day Supply) - Non-Preferred Drugs
- IN-NETWORK
- 20%*
- OUT-OF-NETWORK
- Not covered
TierMail Order RX (90-Day Supply) - Generic Drugs
- IN-NETWORK
- 20%*
- OUT-OF-NETWORK
- Not covered
TierMail Order RX (90-Day Supply) - Preferred Drugs
- IN-NETWORK
- 20%*
- OUT-OF-NETWORK
- Not covered
TierMail Order RX (90-Day Supply) - Non-Preferred Drugs
- IN-NETWORK
- 20%*
- OUT-OF-NETWORK
- Not covered
TierMail Order RX (90-Day Supply) - Specialty / Specialty Injectibles
- IN-NETWORK
- 20%*
- OUT-OF-NETWORK
- Not covered
- *After deductible