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Medical Plan Highlights and Changes Open Access Plus In-Network

Open Access Plus

(OAPIN)

(OAP)

Single

Deductible

The most you’ll pay next year out-of-pocket

Copays apply Copays apply

$5,000

$6,000

HRA contribution from employer Inpatient Hosp Outpatient Fac INN: In-Network OON: Out of Network

Family

n/a $200/day –max 4

15%

$200

15%

$10,000 $12,000

n/a

Single $500 INN/ $1,000 OON

Family $1,500 INN/ $3,000 OON

$10,000 $5,000 $5775 $11,550 INN/ INN/

CIGNA Choice Fund® with Health Reimbursement Arrangement (HRA)*

Single

Emp + Spouse

Family

$1,000 INN/ $3,000 OON

Emp + Child $2,000 INN/ $4,000 OON

$3,000 INN/ $6,000 OON

$3,000 INN/

$6,000 INN/

$9,000 INN/

$6,000

$12,000

$18,000

$10,000

$20,000

$11,550

$23,100

OON

OON

OON

OON

OON

n/a

n/a

$500

$1,000

$1,500

CYD 15% INN

CYD 15% INN CYD 15% INN CYD 15% INN CYD 15% INN

CYD 30% OON CYD 30% OON CYD: Calendar Year Deductible CCN: CIGNA Care Network

CYD 30% OON

CYD 30% OON

PCP: Primary Care Physician

No changes to Prescription Copays. Remember, you also have access to Convenience Clinics, for a PCP copay, located at many drug stores and pharmacies. Please refer to your Benefit Certificate booklet for a comprehensive view of your plan benefits.

CYD 30% OON


Medical Plan Highlights and Changes (continued)

Benefit

Open Access Plus In-Network (OAPIN)

Open Access Plus (OAP) IN-Network

OAP with Choice Fund (HRA) IN-Network

OUT of Network

Office Visit :

$20 PCP

$15 PCP

CYD 15% CCN

PCP:

$30 $40 Spec CCN

$25 $30 Spec CCN

CYD 20% Non CCN

Specialist – CIGNA Care Network

$45 $60 Spec. Non CCN

$40 $45 Spec Non CCN

CYD then 30%

OUT of Network

CYD then 30%

Specialist- Non CIGNA Care Network Coinsurance (e.g., inpatient) CCN Non-CCN Ambulatory/Surgical Centers Emergency Room Urgent Care INN: In-Network OON: Out of Network

CYD then 15% N/A

15%

$75 copay then 100% $150

$200

$35 $50

CYD then 15% CYD then 30%

CYD then 15% $75 copay then 100%

CYD then 30%

$150

$150

$35

$35

CYD: Calendar Year Deductible CCN: CIGNA Care Network

CYD then 20% CYD then 15%

CYD then 15%

CYD then 30%

CYD then 30% CYD then 15%

PCP: Primary Care Physician


/CIGNA2011BENEFITCHANGES3