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Plan Type PPO
Metal Level Silver
Office Visit for Primary Doctor
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$30, deductible waived visits 1-2, then 30% after deductible
Office Visit for Specialist $60, deductible waived visits 1-2, then 30% after deductible
Office Visit for Other Practitioner (Nurse, Physician Assistant) $60, deductible waived visits 1-2, then 30% after deductible
Annual Deductible Individual: $1,500
Separate Prescription Drugs Deductible Medical plan deductible applies to Non-preferred Brand and Specialty only
Coinsurance 30% after deductible
Retail Prescription Drugs Preferred Generic: $4 Copay
Non-preferred Generic: $20 Copay
Preferred Brand: $60 Copay
Non-preferred Brand: 50% after deductible
Specialty: 40% after deductible
Annual Out-of-Pocket Limit Individual: $6,350
Includes deductible
Lifetime Maximum Unlimited
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage Yes  (Details in plan brochure below)
Out-of-Country Coverage Yes. All Services 
Office Visit
Primary Care Physician Required No
Specialist Referrals Required No
Preventive Care Coverage
Periodic Health Exam No Charge
Periodic OB-GYN Exam No Charge
Well Baby Care No Charge
Emergency and Urgent Care
Emergency Room 30% Coinsurance after deductible
Emergency Ambulance Services 30% Coinsurance after deductible
Urgent Care Facility $75 Copay
Prescription Drug Coverage
Retail Prescription Drugs Preferred Generic: $4 Copay
Non-preferred Generic: $20 Copay
Preferred Brand: $60 Copay
Non-preferred Brand: 50% after deductible
Specialty: 40% after deductible
Separate Prescription Drugs Deductible Medical plan deductible applies to Non-preferred Brand and Specialty only
Mail Order Prescription Drugs Preferred Generic: $10 Copay
Non-preferred Generic: $50 Copay
Preferred Brand: $150 Copay
Non-preferred Brand: 50% after deductible
Specialty: 30% after deductible
Mail Order Supply 90, except specialty which will be 30
Outpatient Coverage
Outpatient Surgery 30% Coinsurance after deductible
Outpatient Lab/X-Ray 30% Coinsurance after deductible
Imaging (CT and PET scans, MRIs) 30% Coinsurance after deductible
Outpatient Mental Health 30% Coinsurance after deductible
Outpatient Substance Abuse 30% Coinsurance after deductible
Outpatient Rehabilitation Services (PT, OT, ST) 30% Coinsurance after deductible (35 visits/year combined in and out of network)
Inpatient Coverage
Hospitalization 30% Coinsurance after deductible
Skilled Nursing Facility 30% Coinsurance after deductible (Calendar year maximum of 60 days, combined in- and out-of-network)
Inpatient Mental Health 30% Coinsurance after deductible
Inpatient Substance Abuse 30% Coinsurance after deductible
Home Healthcare 30% Coinsurance after deductible (Calendar year maximum of 20 visits, combined in- and out-of-network)
Maternity Coverage
Pre & Postnatal Office Visit 30% Coinsurance after deductible
Labor & Delivery Hospital Stay 30% Coinsurance after deductible
Pediatric Services
Dental Checkup for Children No Charge after $50 dental deductible. Applies to ages 1-19.
Vision Screening for Children No Charge. Children up to age 19. Limited to 1 visit per 12 month period.
Eye Glasses for Children No Charge. Children up to age 19. Limited to 1 pair of glasses (lenses and frames from pediatric selection) per 12 month period.
Major Dental Coverage (Pediatric) 50% Coinsurance after $50 dental deductible.
Additional Coverage
Chiropractic Coverage 30% Coinsurance after deductible (26 visits per year)
Durable Medical Equipment 30% Coinsurance after deductible
Hospice 30% Coinsurance after deductible
Major Dental Coverage (Adult) Not Covered
Vision Coverage (Adult) Not Covered
Out-of-Network Coverage
Out-of-Network Authorization Required No
Out-of-Network Annual Deductible $6,000 Individual/$12,000 Family
Out-of-Network Annual Coinsurance 50% after deductible
Out-of-Network Annual Out-of-Pocket Limit $25,000 Individual/$50,000 Family
Additional Information
A.M. Best Rating A as of 02/13/2014
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure

The carrier has not provided a separate document for Exclusions and Limitations.

Summary of Benefits & Coverage (Not available)

The Summary of Benefits & Coverage can be found at healthcare.gov. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.

Customer reviews

Important notices and disclaimers

  • The benefits matrix is a summary for informational purposes only. Review the evidence of coverage and insurance policy (plan contract) for a detailed description of coverage benefits, limitations, and exclusions. Only the terms and conditions of coverage benefits listed in the policy are binding.
  • The benefits listed may be contingent on your use of physicians, hospitals, and services within the specific insurance company's provider network.
  • The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. These amounts are subject to change.
  • Each insurance carrier may have unique Notices, Disclaimers, and Fees. Please check below for information regarding the plans and carriers you selected.
  • The quotes or rates shown above are estimates only. Your premium is subject to change based on the optional benefits you selected, if any, and other relevant factors, such as changes in rates that take effect before your coverage start date. The insurance company always determines your actual premium. Insurance companies reserve the right to change the terms of a policy upon proper notification.
  • The Summary of Benefits & Coverage can be found at healthcare.gov. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.

Carrier specific notices, disclaimers and fees

  • Cigna - These plans are intended to comply with the federal Patient Protection and Affordable Care Act (PPACA). Provisions are subject to change as additional regulatory guidance becomes available.