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City of Cocoa I Employee Benefit Highlights I 2020-2021ErLIF1 <br /> Cigna Core Plan At-A-Glance <br /> Network Open Access Plus <br /> Calendar Year Deductible(CYD) In-Network <br /> [Single ______________,_ _�_ $2,000 <br /> Family $6,000 <br /> Coinsurance _ Locate a Provider <br /> Member Responsibility 20% <br /> 1To search for a participating provider, <br /> Calendar Year Out-of-Pocket Limit contact Cigna's customer service or visit <br /> f www.mycigna.com.When completing <br /> I Single $6,000 <br /> the necessary search criteria,select <br /> Family J $12,000 Open Access Plus network. <br /> f What Applies to the Out-of-Pocket Limit? Coinsurance,Deductible,Copays,and Rx <br /> Physician Services <br /> I . 0 <br /> Primary Care Physician(PCP)through Employee Health Center __j No Charge <br /> Primary Care Physician(PCP)Office Visit(No PCP Election Required) $25 Copay <br /> I Specialist Office Visit(No ReferralRequired) _ $50 Copay Plan References <br /> [Telehealth Services No Charge *La6CorporQuest Diagnostics are the <br /> Non-Hospital Services;Freestanding Facility preferred labs for bloodwork through <br /> Cigna.When using a lab other than <br /> 1 Clinical Lab(bloodwork)through Employee Health Center No Charge LabCorp or Quest please confirm they <br /> Clinical Lab(Bloodwork)* No Charge are contracted with agna's Open Access <br /> Plus network prior to receiving services. <br /> f X-rays _J No Charge <br /> Advanced Imaging(MRI,PET CT)-Per Scan,Per Day $100 Copay <br /> LOutpatient Surgery in Surgical Center 20%After CYD <br /> Physician Services at Surgical Center 1 20%After CYD <br /> . 0L <br /> t Urgent Care(Per Visit) , $50 Copay <br /> - - Important Notes <br /> Hospital Services <br /> Services received by providers or <br /> Inpatient Hospital(Per Admission) - 20%After CYD facilities not in the Open Access Plus <br /> [Outpatient Hospital(Per Visit) 20%After CYD network,will not be covered. <br /> Physician Services at Hospital 20%After CYD <br /> {Emergency Room(Per Visit;Waived if Admitted) $250 Copay <br /> Mental Health/Alcohol&Substance Abuse <br /> Inpatient Hospital Services(Per Admission) 20%After CYD <br /> I Outpatient Services(Per Visit) .1 No Charge <br /> Outpatient Office Visit � $50 Copay <br /> Prescription Drugs(Rx) <br /> Ge eric through Employee Health Center _I No Charge <br /> t- <br /> r <br /> iGeneric —] $20 Copay <br /> Preferred Brand Name $40 Copay <br /> Non-Preferred Brand Name $70 Copay <br /> I Mail Order Drug(90-Day Supply) __ _ - i 2x Retail Copay <br /> 16 <br /> 8 <br /> ©2016,Gehring Group,Inc.,All Rights Reserved <br />