Note |
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The figures in the chart below reflect what the Plan pays, with the exception of deductibles and out-of-pocket maximums, which employees pay.
|
Individual Annual Deductible |
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In-Network:
$600
Out-of-Network:
$1,200
| In-Network:
$1,200
Out-of-Network:
$2,500
| In-Network:
$2,300 (includes prescription drugs)
Out-of-Network:
$4,600 (includes prescription drugs)
|
Family Deductible |
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In-Network:
$1,250
Out-of-Network:
$2,500
| In-Network:
$2,500
Out-of-Network:
$5,000
| In-Network:
$4,600 (includes prescription drugs)
Out-of-Network:
$9,200 (includes prescription drugs)
|
Individual Out-of-Pocket Maximum |
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In-Network:
$2,000
Out-of-Network:
$4,000
| In-Network:
$3,000
Out-of-Network:
$7,500
| In-Network:
$5,500 (includes prescription drugs)
Out-of-Network:
$11,000 (includes prescription drugs)
|
Family Out-of-Pocket Maximum |
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In-Network:
$5,000
Out-of-Network:
$10,000
| In-Network:
$7,500
Out-of-Network:
$15,000
| In-Network:
$11,000 (includes prescription drugs)
Out-of-Network:
$20,000 (includes prescription drugs)
|
Diagnostic and Preventive Care |
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In-Network:
100% (no annual deductible)
Out-of-Network:
100% up to a maximum of $250 (no annual deductible) then 60% of eligible expenses (no annual deductible)
| In-Network:
100% (no annual deductible)
Out-of-Network:
100% up to a maximum of $250 (no annual deductible) then 60% of eligible expenses (no annual deductible)
| In-Network:
100% (no annual deductible)
Out-of-Network:
100% up to a maximum of $250 (no annual deductible) then 60% of eligible expenses (no annual deductible)
|
Most other services, including inpatient and outpatient hospital and specialist visits |
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In-Network:
80% after annual deductible
Prior proof of medical necessity may apply for certain services. Check with your health plan administrator to verify coverage and if preauthorization is required.
Out-of-Network:
60% of eligible expenses after annual deductible
Prior proof of medical necessity may apply for certain services. Check with your health plan administrator to verify coverage and if preauthorization is required.
| In-Network:
80% after annual deductible
Prior proof of medical necessity may apply for certain services. Check with your health plan administrator to verify coverage and if preauthorization is required.
Out-of-Network:
60% of eligible expenses after annual deductible
Prior proof of medical necessity may apply for certain services. Check with your health plan administrator to verify coverage and if preauthorization is required.
| In-Network:
80% after annual deductible
Prior proof of medical necessity may apply for certain services. Check with your health plan administrator to verify coverage and if preauthorization is required.
Out-of-Network:
60% of eligible expenses after annual deductible
Prior proof of medical necessity may apply for certain services. Check with your health plan administrator to verify coverage and if preauthorization is required.
|
Cancer Support Program |
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In-Network:
100% covered after annual deductible if enrolled in program within 30 days of diagnosis. 80% after annual deductible if not enrolled in program.
Out-of-Network:
60% after annual deductible
| In-Network:
100% covered after annual deductible if enrolled in program within 30 days of diagnosis. 80% after annual deductible if not enrolled in program.
Out-of-Network:
60% after annual deductible
| In-Network:
100% covered after annual deductible if enrolled in program within 30 days of diagnosis. 80% after annual deductible if not enrolled in program.
Out-of-Network:
60% after annual deductible
|
Bariatric Surgery |
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In-Network:
Cigna: 100% at Cigna Certified Hospitals for bariatric surgery; 80% after annual deductible at other in-network facilities.
UHC: Surgery must be received at a UHC designated Center of Excellence (COE) and will be covered at 100% no annual deductible; all other services related to the surgery covered at 80% after annual deductible.
Out-of-Network:
Cigna: 60% of eligible expenses after annual deductible
UHC: No coverage
| In-Network:
Cigna: 100% at Cigna Certified Hospitals for bariatric surgery; 80% after annual deductible at other in-network facilities.
UHC: Surgery must be received at a UHC designated Center of Excellence (COE) and will be covered at 100% no annual deductible; all other services related to the surgery covered at 80% after annual deductible.
Out-of-Network:
Cigna: 60% of eligible expenses after annual deductible
UHC: No coverage
| In-Network:
Cigna: 100% after annual deductible at Cigna Certified Hospitals for bariatric surgery; 80% after annual deductible at other in-network facilities.
UHC: Surgery must be received at a UHC designated Center of Excellence (COE) and will be covered at 100% no annual deductible; all other services related to the surgery covered at 80% after annual deductible.
Out-of-Network:
Cigna: 60% of eligible expenses after annual deductible
UHC: No coverage
|
Maternity |
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In-Network:
80% after annual deductible
Out-of-Network:
60% of eligible expenses after annual deductible
| In-Network:
80% after annual deductible
Out-of-Network:
60% of eligible expenses after annual deductible
| In-Network:
80% after annual deductible
Out-of-Network:
60% of eligible expenses after annual deductible
|
Fertility Coverage (includes cryopreservation, artificial insemination, IVF, GIFT and ZIFT) |
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In-Network:
Cigna: 80% after annual deductible
UHC: Members must enroll in the Fertility Solutions program and treatment must be received at UHC’s Centers of Excellence; 80% after annual deductible.
Out-of-Network:
Cigna: 60% of eligible expenses after annual deductible
UHC: No coverage
| In-Network:
Cigna: 80% after annual deductible
UHC: Members must enroll in the Fertility Solutions program and treatment must be received at UHC’s Centers of Excellence; 80% after annual deductible.
Out-of-Network:
Cigna: 60% of eligible expenses after annual deductible
UHC: No coverage
| In-Network:
Cigna: 80% after annual deductible
UHC: Members must enroll in the Fertility Solutions program and treatment must be received at UHC’s Centers of Excellence; 80% after annual deductible.
Out-of-Network:
Cigna: 60% of eligible expenses after annual deductible
UHC: No coverage
|