Deductibles, Coinsurance and Out-of-Pocket Maximums
|
Plan |
Annual Deductible*
Individual/Family Maximum |
Co-insurance |
Out-of-Pocket Maximum* |
In-Network
Cigna 350 |
$350/$1,050 |
80% |
$2,500/$5,000 |
Out-of-Network
Cigna 350 |
$1,000/$3,000 |
60% |
$5,000/$10,000 |
In-Network
SafeNet |
$1,000/$3,000 |
80% |
$3,000/$6,000 |
Out-of-Network
SafeNet |
$1,000/$3,000 |
60% |
$3,000/$6,000 |
* Co-pays do not count towards deductibles or out-of-pocket maximums
Co-pays (per visit)
|
Plan |
Primary Care Physician |
Specialist |
Hospital |
Emergency Room |
In-Network
Cigna 350 |
$20** |
$35 |
$100 inpatient |
$75 |
Out-of-Network
Cigna 350 |
N/A |
N/A |
N/A |
$75 |
SafeNet |
N/A |
N/A |
N/A |
N/A |
** The $20 co-pay applies to Family Physician, General Practitioner, Internal Medicine and Pediatrcian visits.
Prescription Drug Co-pays for Cigna 350 and SafeNet
| |
Retail
(30 day supply) |
Mail Order
(90 day supply) |
Generic |
$10 |
$20 |
Formulary Brand |
$25 |
$50 |
Non-formulary Brand |
$40 |
$80 |
Weekly Associate Costs
Plan
| Weekly Cost for Associates with at least 6 months of service (Company Contribution Applies)
| Weekly Cost for Associates with less than 6 months of service (Associate Pays Full Cost) |
|
Assoc. |
Assoc. & 1 |
Assoc. & 2+ |
Assoc. |
Assoc. & 1 |
Assoc. & 2+ |
| Cigna 350 |
$25.14 |
$57.35 |
$74.62 |
$64.46 |
$145.00 |
$188.17 |
|
SafeNet |
$22.95 |
$52.36 |
$68.13 |
$58.85 |
$132.38 |
$171.79 |
|
