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Benefit Comparison

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	Base High Deductible	Value High Deductible	Choice Open Access
Services	In-Network	In-Network	In-Network
Deductible ·       Individual ·       Family	Embedded* $4,000 $8,000	Non- Embedded** $2,500 $4,500	Embedded* $1,000 $2,000
Coinsurance ·       Plan Pays ·       You Pay	80% 20%	80% 20%	70% 30%
Out-of-Pocket Max ·       Individual ·       Family	$6,000 $12,000	$5,000 $10,000	$4,000 $8,000
Preventive Services	Covered at 100%	Covered at 100%	Covered at 100%
Primary Care	20% after deductible	20% after deductible	$30 copay
Specialist Visit	20% after deductible	20% after deductible	$60 copay
Virtual Care	20% after deductible; $55 average cost per visit	20% after deductible; $55 average cost per visit	$25 copay
Urgent Care	20% after deductible	20% after deductible	$60 copay
Emergency Room	20% after deductible	20% after deductible	30% after deductible
Hospitalization	20% after deductible	20% after deductible	30% after deductible
Once Annual Eye Exam	$15 Copay	$15 Copay	$15 Copay
Services	Out-of-Network	Out-of-Network	Out-of-Network
Deductible ·       Individual ·       Family	Embedded $5,000 $10,000	Non-Embedded $4,000 $8,000	Embedded $2,000 $4,000
Coinsurance ·       Plan Pays ·       You Pay	60% 40%	60% 40%	50% 50%
Out-of-Pocket Max ·       Individual ·       Family	$10,000 $20,000	$8,000 $16,000	$6,500 $13,000

The way the deductible and the out of pocket maximum work is important if you cover anyone other than yourself.

• With the Choice Open Access and the Base High Deductible $4,000 (Embedded), after each eligible family member meets their individual deductible and individual out of pocket maximum, covered expenses for that family member will be paid based on the coinsurance level specified by the plan. Or, after the family deductible has been met, covered expenses for each eligible family member will be paid based on the coinsurance level specified by the plan.
• With the Value High Deductible $2,500 (Non-Embedded), all eligible family members contribute towards the family plan deductible and out of pocket maximum. The family deductible and the family out of pocket maximum must be met before the plan will pay each eligible family member's covered expenses based on the coinsurance level specified by the plan.

** No charge for wellness visits as long as the doctor's office codes the visit as a preventative check-up.

The above information is not a complete list of covered and excluded services and is for informational purposes only. If there is a discrepancy between the above information and that of the official Cigna Group Contract & Summary Plan Description (SPD), the Cigna Group Contract & SPD will prevail. Please see the Cigna SPD for complete details on benefits, exclusions, and limitations.