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Cigna Plans

The following is a summary of your medical benefits. For a more detailed explanation of benefits, please refer to your Summary Plan Description (SPD), certificate of coverage or SBC. You may access a list of participating providers through the carrier’s website.

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To access the list of contracted providers through Partners Direct Health and HealthSmart, please refer to the Find A Provider tool in miBenefits.

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HDHP Plan

	In-Network	Out-of-Network
Deductibles
Per plan participant	$2,500	$3,000
Per family unit	$5,000	$6,000
Coinsurance
Plan pays	80%	60%
You pay	20%	40%
Out-of-Pocket Maximum
Per plan participant	$5,000	$10,000
Per family unit	$10,000	$20,000
Covered Services
Office Visit Primary care Specialist	80% After Deductible 80% After Deductible	60% After Deductible 60% After Deductible
Preventive care	No charge	No charge
Urgent care Facility Physician	80% After Deductible 80% After Deductible	60% After Deductible 60% After Deductible
Emergency room	80% after deductible, then $500 copay per visit (copay waived if admitted)	80% after deductible, then $500 copay per visit (copay waived if admitted)
Diagnostic lab & x-ray Facility Physician	80% After Deductible 80% After Deductible	60% After Deductible 60% After Deductible
Inpatient stay Facility Physician	80% After Deductible 80% After Deductible	60% After Deductible 60% After Deductible

PPO Plan

	In-Network	Out-of-Network
Deductibles
Per plan participant	$500	$1,000
Per family unit	$1,500	$3,000
Coinsurance
Plan pays	80%	60%
You pay	20%	40%
Out-of-Pocket Maximum
Per plan participant	$5,000	$10,000
Per family unit	$10,000	$20,000
Covered Services
Office Visit Primary care Specialist	80% After Deductible 80% After Deductible	60% After Deductible 60% After Deductible
Preventive care	No charge	No charge
Urgent care Facility Physician	80% After Deductible 80% After Deductible	60% After Deductible 60% After Deductible
Emergency room	80% after deductible, then $500 copay per visit (copay waived if admitted)	$500 copay per visit, then 80% after deductible (copay waived if admitted)
Diagnostic lab & x-ray Facility Physician	80% After Deductible 80% After Deductible	60% After Deductible 60% After Deductible
Inpatient stay Facility Physician	80% After Deductible 80% After Deductible	60% After Deductible 60% After Deductible