Cigna Health and Life Insurance Company

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Plan Overview

Medical Deductible	Individual: $5,000 Family: $10,000 Per Person: $5,000
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $8,000 Family: $16,000 Per Person: $8,000
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: $40 Copay
Specialist	Standard: $80 Copay

Prescription Drug Information

Preferred Brand Drugs	Standard: $40 Copay
Non Preferred Brand Drugs	Standard: $80 Copay after deductible
Generic Drugs	Standard: $20 Copay
Specialty Drugs	Standard: $350 Copay after deductible

Inpatient Coverage

Hospital Services	Standard: 40% Coinsurance after deductible
Inpatient Services	Standard: 40% Coinsurance after deductible

Emergency and Urgent Care

Emergency Room

Standard: 40% Coinsurance after deductible

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Cigna HealthCare of Arizona, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of North Carolina, Inc. and Cigna Dental Health, Inc. The Cigna name, logo and other Cigna marks are owned by Cigna Intellectual Property, Inc.

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Plan Overview

Office Visit

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

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