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Cigna POS Individual Health Insurance In-Network Benefit Summary* (click here for out-of-network benefit summary)
Description of Benefits		Open Access $1,000 Deductible	Open Access $2,000 Deductible	Open Access $3,000 Deductible	Open Access $5,000 Deductible
Annual Deductible Per Member (2 person maximum)		$1,000	$2,000	$3,000	$5,000
Annual Out-of-Pocket Maximum (3 person family maximum)		$2,000 plus deductible per member	$3,000 plus deductible per member	$4,000 plus deductible per member	$5,000 plus deductible per member
Lifetime Maximum Per Member		$5,000,000	$5,000,000	$5,000,000	$5,000,000
Office Visit Copay - (Physicians/Specialists) Deductible is waived for office vsits unless billed as an in-office surgical procedure		$25/$35	$25/$35	$35/$45	$35/$45
Preventive Care for Babies and Children (through age 5)		$25/$35 Lab/Immunizations covered at 80% with ded. waived	$25/$35 Lab/Immunizations covered at 80% with ded. waived	$25/$35 Lab/Immunizations covered at 80% with ded. waived	$25/$35 Lab/Immunizations covered at 80% with ded. waived
Preventive Screenings for Ages 6 and Above ($300 calendar year max) includes immunizations, flu shots and lab work *Colonscopy will be paid at coinsurance rate after the yearly deductible is met.		$25/$35	$25/$35	$35/$45	$35/$45
Mammograms, PAP Smear, PSA and Colorectal Screening		Covered at 80% with deductible waived	Covered at 80% with deductible waived	Covered at 70% with deductible waived	Covered at 70% with deductible waived
Diagnostic Services Includes Lab and X-Ray		Plan pays 100% with deductible waived for first $200/year, then 80% after deductible for remainder	Plan pays 100% with deductible waived for first $200/year, then 80% after deductible for remainder	Plan pays 100% with deductible waived for first $200/year, then 70% after deductible for remainder	Plan pays 100% with deductible waived for first $200/year, then 70% after deductible for remainder
Professional Services Including surgery, anesthesia, in-hospital physician care		Plan pays 80% after deductible	Plan pays 80% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible
Inpatient Hospital Services Surgery, x-ray, in-hospital physician visits, organ/tissue transplants		Plan pays 80% after deductible	Plan pays 80% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible
Maternity		NOT COVERED	NOT COVERED	NOT COVERED	NOT COVERED
Outpatient Medical Care		Plan pays 80% after deductible	Plan pays 80% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible
Short Term Therapies: Physical/Occupational/Speech Therapy (Calendar Year Max of 24 visits) Developmental Delay is not covered		Plan pays 80% after deductible	Plan pays 80% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible
Cardiac and Pulmonary Rehabilitation		Plan pays 80% after deductible	Plan pays 80% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible
Chiropractic Services (24 visits per year )		Plan pays 80% after deductible	Plan pays 80% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible
Mental Health- (48 O/P Vis & 30 I/P days per calendar yr.)		Plan pays 80% after deductible	Plan pays 80% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible
Infusion Therapy/Chemotherapy		Plan pays 70% after deductible	Plan pays 70% after deductible	Deductible	Plan pays 70% after deductible
Emergency Room Care - For Medical Emergency or Serious Accidental Injury (Additional deductible waived if admitted) (Non emergency use of the emergency room is not a covered benefit)		$100 addidtional deductible then plan pays 80% after medical deductible	$100 addidtional deductible then plan pays 80% after medical deductible	$100 addidtional deductible then plan pays 80% after medical deductible	$100 addidtional deductible then plan pays 80% after medical deductible
Urgent Care		Plan pays 80% after deductible	Plan pays 80% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible
Ambulatory Surgical Center		Plan pays 80% after deductible	Plan pays 80% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible
Ambulance Service		Plan pays 80% after deductible	Plan pays 80% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible
Hospice		Plan pays 80% after deductible	Plan pays 80% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible
Home Health Care - Limited to 60 days, in and out of network combined		Plan pays 80% after deductible	Plan pays 80% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible
Durable Medical Equipment, Prosthetics and Orthoses		Plan pays 80% after deductible	Plan pays 80% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible
Skilled Nursing Facility Limited to 30 days, in and out of network combined		Plan pays 80% after deductible	Plan pays 80% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible
Organ and Tissue Transplants		Plan pays 100% after deductible at Cigna Lifesource Transplant facility Plan pays 80% at other in-net	Plan pays 100% after deductible at Cigna Lifesource Transplant facility Plan pays 80% at other in-net	Plan pays 100% after deductible at Cigna Lifesource Transplant facility Plan pays 70% at other in-net	Plan pays 100% after deductible at Cigna Lifesource Transplant facility Plan pays 70% at other in-net
Prescription Drugs - Retail Drugs - per prescription (up to a 30-day supply-mail order available)		After a $100 brand name drug deductible per person, you pay:	After a $200 brand name drug deductible per person, you pay:	After a $300 brand name drug deductible per person, you pay:	After a $500 brand name drug deductible per person, you pay:
	Tier 1 (Generic Drugs) (AVAILABLE WITHOUT MEETING ANY DEDUCTIBLE)	$10 copayment	$10 copayment	$10 copayment	$10 copayment
	Tier 2 (Formulary Brand)	$35 copayment	$35 copayment	$35 copayment	$35 copayment
	Tier 3 (Non-Formulary Brand)	$60 copayment	$60 copayment	$60 copayment	$60 copayment
	Tier 4 (self edministered injectables)	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible
	Home Delivery Pharmacy (90 day supply)-generic/brand/non-preferred	$25/$80/$150 Copay	$25/$80/$150 Copay	$25/$80/$150 Copay	$25/$80/$150 Copay
	Home Delivery Pharmacy (90 day supply)-self admin injectibles	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible
Description of Benefits		Open Access $1,000 Deductible	Open Access $2,000 Deductible	Open Access $3,000 Deductible	Open Access $5,000 Deductible
Waiting period for all undisclosed pre-existing conditions is at least one year from contract effective date. *Refer to your individual certificate of coverage for complete benefit details-illustration above to be used as a summary only. (As with all insurance providers, not disclosing known prexisting conditions could result in termination of your benefits)
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