PLAN: Cigna 2500 Classic UID: Cigna 2500 Classic Category: Major Medical Type: PPO Marketing Name: Cigna - 2,500 Plan Average Price: $1118.73 Short Description: A dependable PPO with a moderate deductible and consistent copays that make budgeting easier. Long Description: The Cigna 2500 Plan is built for people who want reliable coverage with manageable costs. You’ll pay $30 for primary care and $60 for specialists, with preventive care fully covered. It’s a good middle-ground plan that works well for most people. PRICING: Coverage 4: $1702.35 Coverage 3: $1035.36 Coverage 2: $1146.52 Coverage 1: $590.71 DETAILS: COVERAGE: Notes: Yes. If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Coverage Tier: All Emergency Room: You pay the full cost until your deductible is met, then 20% of the covered amount. Monthly Premium: None Lifetime Maximum: No Maximum Professoinal Fees: You pay the full cost until your deductible is met, then 20% of the covered amount. Referral Required: No Urgent Care Copay: 80 Employee Contribution: TBD by Group Employer Contribution: TBD by Group Inpatient Hospital Stay: You pay the full cost until your deductible is met, then 20% of the covered amount. Habilitation - In Network: You pay the full cost until your deductible is met, then 0% of the covered amount subject to plan's allowable fee. Included no cost services: 0% Copay Telemedicine, Virtual Primary Care, Advocay Services Prescription Drug Deductible: You just pay low copays for medications right away—no deductible needs to be met. Habilitation - Out of Network: You pay the full cost until your deductible is met, then 40% of the covered amount subject to plan's allowable fee. Home heslth care - In Network: You pay the full cost until your deductible is met, then 20% of the covered amount subject to plan's allowable fee. Hospice services - In Network: You pay the full cost until your deductible is met, then 40% of the covered amount subject to plan's allowable fee. Specialist Copay - In Network: 60 Emergency Medical Transporation: You pay the full cost until your deductible is met, then 20% of the covered amount. Primary Care Copay - In Network: 30 Your Rights to Continue Coverage: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explaination of benefits you will receivefor that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan.For more information about your rights, this notice, or assistance, contact: Acuity at 1-866-872-6356 or Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Deductible (Family) - In Network: 5000 Home heslth care - Out of Network: You pay the full cost until your deductible is met, then 40% of the covered amount subject to plan's allowable fee. Hospice services - Out of Network: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is :Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. Skilled nursing care - In Network: You pay the full cost until your deductible is met, then 20% of the covered amount subject to plan's allowable fee. Specialist Copay - Out of Network: You pay the full cost until your deductible is met, then 40% of the covered amount. Your Grievance and Appeals Rights: Yes. If you don't have Minimum Essential Coverage for a month, you'll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Specialty Drugs - Network Provider: 50% coinsurance Primary Care Copay - Out of Network: You pay the full cost until your deductible is met, then 40% of the covered amount. Chiropractic Care Copay - In Network: 20 Deductible (Family) - Out of Network: 10000 Deductible (Individual) - In Netwok: 2500 Pregnancy office visits - In Network: You pay the full cost until your deductible is met, then 20% of the covered amount subject to plan's allowable fee. Rehabilitation Services - In Network: You pay the full cost until your deductible is met, then 0% of the covered amount subject to plan's allowable fee. Skilled nursing care - Out of Network: You pay the full cost until your deductible is met, then 40% of the covered amount subject to plan's allowable fee. Durable medical equipment - In Network: You pay the full cost until your deductible is met, then 20% of the covered amount subject to plan's allowable fee. Chiropractic Care Copay - Out of Network: NA Deductible (individual) - Out of Netwok: 5000 Pregnancy office visits - Out of Network: You pay the full cost until your deductible is met, then 40% of the covered amount subject to plan's allowable fee. Rehabilitation Services - Out of Network: You pay the full cost until your deductible is met, then 40% of the covered amount subject to plan's allowable fee. Specialty Drugs - Out of Network Provider: Not covered Durable medical equipment - Out of Network: You pay the full cost until your deductible is met, then 20% of the covered amount subject to plan's allowable fee. Out of Pocket Maximum (Family) - In Network: 14700 Routine Preventive Services (Non-Diagnostic): No Member Cost Sharing - Deductible Waived Out of Pocket Maximum (family) - Out of Network: 29400 Does this plan meet the Minimum Value Standards?: None Out of Pockert Maximum (Individual) - In Network: 7350 Cildbirth/delivery facility services - In Network: You pay the full cost until your deductible is met, then 20% of the covered amount subject to plan's allowable fee. Coinsurance % (Plan pays/Member Pays) - In Network: 80% / 20%% Does This Plan provide Minimum Essential Coverage?: For more information about limitations and exceptions, see the plan or policy document at https://www.acuity-grp.com Out of Pocket Maximum (Individual) - Out of Network: 14700 Blood test to help diagnose a condition - In Network: You pay the full cost until your deductible is met, then 20% of the covered amount. Cildbirth/delivery facility services - Out of Network: You pay the full cost until your deductible is met, then 40% of the covered amount subject to plan's allowable fee. Free Standing Lab & Diagnostic Services (Lab & x-ray): You pay the full cost until your deductible is met, then 0% of the covered amount. Preventative Care/Screening/Immunization - In Network: 0% Coinsurance Childbirth/delivery professional services - In Network: You pay the full cost until your deductible is met, then 20% of the covered amount subject to plan's allowable fee. Coinsurance % (Plan pays/Member Pays) - Out of Network: 60% / 40% Blood test to help diagnose a condition - Out of Network: You pay the full cost until your deductible is met, then 40% of the covered amount subject to plan's allowable fee. Preventative Care/Screening/Immunization - Out of Network: Not Covered Childbirth/delivery professional services - Out of Network: You pay the full cost until your deductible is met, then 40% of the covered amount subject to plan's allowable fee. Imaging tests like X-Rays, CT/PET Scans, or MRI's - In Network: You pay the full cost until your deductible is met, then 20% of the covered amount subject to plan's allowable fee. Out Patient Services, Surgical Services (Procedure & Anesthesia): You pay the full cost until your deductible is met, then 20% of the covered amount. Imaging tests like X-Rays, CT/PET Scans, or MRI's - Out of Network: You pay the full cost until your deductible is met, then 40% of the covered amount subject to plan's allowable fee. Generic medication (30-day supply) from a pharmacy in your plan’s network: $15 copay Generic medication (31-90-day supply) from a pharmacy in your plan’s network: $45 copayemnt Inpatient mental/ behavioral health, and substance abuse services - In Network: You pay the full cost until your deductible is met, then 20% of the covered amount subject to plan's allowable fee. Complex Diagnositc Services (CT, MRI, Ultra Sound, PET, Nuclear Med.) (Network): You pay the full cost until your deductible is met, then 20% of the covered amount. Outpatient mental/ behavioral health, and substance abuse services - In Network: $30 copay Inpatient mental/ behavioral health, and substance abuse services - Out of Network: You pay the full cost until your deductible is met, then 40% of the covered amount subject to plan's allowable fee. Outpatient mental/ behavioral health, and substance abuse services - Out of Network: You pay the full cost until your deductible is met, then 40% of the covered amount subject to plan's allowable fee. Brand-name medication that’s on your plan’s preferred list (30-day supply from an in-network pharmacy): $45 copay Brand-name medication that’s on your plan’s preferred list (31-90-day supply) from an in-network pharmacy): $90 copayemnt Brand-name medication that’s not on your plan’s preferred list (30-day supply) from an in-network pharmacy): $85 copay Brand-name medication that’s not on your plan’s preferred list (31-90-day supply) from an in-network pharmacy): $150 copayemnt