New! Cigna SimplePlan

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

EPO

Has Out Of Network Coverage

Premiums

Coverage Tier	SEMI-MONTHLY	BI-WEEKLY	WEEKLY
Employee Only	$105.82	$97.68	$48.84
Employee + Spouse*	$257.43	$237.62	$118.81
Employee + One Child	$151.27	$139.63	$69.82
Employee + Two or More Children	$200.30	$184.89	$92.45
Employee + Family*	$323.56	$298.67	$149.34

Coverage TierEmployee Only

SEMI-MONTHLY: $105.82
BI-WEEKLY: $97.68
WEEKLY: $48.84

Coverage TierEmployee + Spouse*

SEMI-MONTHLY: $257.43
BI-WEEKLY: $237.62
WEEKLY: $118.81

Coverage TierEmployee + One Child

SEMI-MONTHLY: $151.27
BI-WEEKLY: $139.63
WEEKLY: $69.82

Coverage TierEmployee + Two or More Children

SEMI-MONTHLY: $200.30
BI-WEEKLY: $184.89
WEEKLY: $92.45

Coverage TierEmployee + Family*

SEMI-MONTHLY: $323.56
BI-WEEKLY: $298.67
WEEKLY: $149.34

*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 ONLY
Calendar Year Deductible - Individual	$0
Calendar Year Deductible - Family	$0
Coinsurance (Employee Pays)	0%
Calendar Year Out-of-Pocket Maximum (Maximum Includes Deductible) - Individual	$7,500
Calendar Year Out-of-Pocket Maximum (Maximum Includes Deductible) - Family	$15,000
Preventive Care	0%
Mdlive/Virtual Care	MDLive: $0 PCP Virtual Care: Tier 1: $50 / Tier 2: $100 Specialist Virtual Care: Tier 1: $100 / Tier 2: $200
Primary Care	Tier 1: $50 / Non-Tier 1: $100
Specialist	Tier 1: $100 / Non-Tier 1: $200
Urgent Care	$200
Emergency Room	$500
DIAGNOSTIC TEST (X-ray, Blood Work)	PCP: Tier 1: $50 / Non-Tier 1: $100 Specialist: Tier 1: $100 / Non-Tier 1: $200
Mental Health – Inpatient	$2,500
Mental Health – Outpatient	$0

ServiceCalendar Year Deductible - Individual

IN-NETWORK ONLY: $0

ServiceCalendar Year Deductible - Family

IN-NETWORK ONLY: $0

ServiceCoinsurance (Employee Pays)

IN-NETWORK ONLY: 0%

ServiceCalendar Year Out-of-Pocket Maximum (Maximum Includes Deductible) - Individual

IN-NETWORK ONLY: $7,500

ServiceCalendar Year Out-of-Pocket Maximum (Maximum Includes Deductible) - Family

IN-NETWORK ONLY: $15,000

ServicePreventive Care

IN-NETWORK ONLY: 0%

ServiceMdlive/Virtual Care

IN-NETWORK ONLY: MDLive: $0 PCP Virtual Care: Tier 1: $50 / Tier 2: $100 Specialist Virtual Care: Tier 1: $100 / Tier 2: $200

ServicePrimary Care

IN-NETWORK ONLY: Tier 1: $50 / Non-Tier 1: $100

ServiceSpecialist

IN-NETWORK ONLY: Tier 1: $100 / Non-Tier 1: $200

ServiceUrgent Care

IN-NETWORK ONLY: $200

ServiceEmergency Room

IN-NETWORK ONLY: $500

ServiceDIAGNOSTIC TEST (X-ray, Blood Work)

IN-NETWORK ONLY: PCP: Tier 1: $50 / Non-Tier 1: $100 Specialist: Tier 1: $100 / Non-Tier 1: $200

ServiceMental Health – Inpatient

IN-NETWORK ONLY: $2,500

ServiceMental Health – Outpatient

IN-NETWORK ONLY: $0

Prescription Drug Coverage

Tier	IN-NETWORK	OUT-OF-NETWORK
Calendar Year Deductible - Individual	$250	N/A
Calendar Year Deductible - Family	$500	N/A
Retail RX (30-Day Supply) - Preventive Generic Drugs	$0 Copay, no deductible	Not covered
Retail RX (30-Day Supply) - Generic Drugs	$25 copay	Not covered
Retail RX (30-Day Supply) - Preferred Drugs	$50 copay	Not covered
Retail RX (30-Day Supply) - Non-Preferred Drugs	$75 copay	Not covered
Mail Order RX (90-Day Supply) - Generic Drugs	$63 Copay	Not covered
Mail Order RX (90-Day Supply) - Preferred Drugs	$125 Copay	Not covered
Mail Order RX (90-Day Supply) - Non-Preferred Drugs	$188 Copay	Not covered
Mail Order RX (90-Day Supply) - Specialty / Specialty Injectibles	$150 Copay (per 30 days)	Not covered

TierCalendar Year Deductible - Individual

IN-NETWORK: $250
OUT-OF-NETWORK: N/A

TierCalendar Year Deductible - Family

IN-NETWORK: $500
OUT-OF-NETWORK: N/A

TierRetail RX (30-Day Supply) - Preventive Generic Drugs

IN-NETWORK: $0 Copay, no deductible
OUT-OF-NETWORK: Not covered

TierRetail RX (30-Day Supply) - Generic Drugs

IN-NETWORK: $25 copay
OUT-OF-NETWORK: Not covered

TierRetail RX (30-Day Supply) - Preferred Drugs

IN-NETWORK: $50 copay
OUT-OF-NETWORK: Not covered

TierRetail RX (30-Day Supply) - Non-Preferred Drugs

IN-NETWORK: $75 copay
OUT-OF-NETWORK: Not covered

TierMail Order RX (90-Day Supply) - Generic Drugs

IN-NETWORK: $63 Copay
OUT-OF-NETWORK: Not covered

TierMail Order RX (90-Day Supply) - Preferred Drugs

IN-NETWORK: $125 Copay
OUT-OF-NETWORK: Not covered

TierMail Order RX (90-Day Supply) - Non-Preferred Drugs

IN-NETWORK: $188 Copay
OUT-OF-NETWORK: Not covered

TierMail Order RX (90-Day Supply) - Specialty / Specialty Injectibles

IN-NETWORK: $150 Copay (per 30 days)
OUT-OF-NETWORK: Not covered