Cost and Period of Coverage

 Annual*                                                                          

1/1/2019-12/31/2019                                                                           

Student Only

$1,950

    Dependent rates are in addition to the student rate

Spouse 

$1,950

Each Child

$1,950

             *Premiums include an Administrative Service Fee

Network

Non-Network

Plan Maximum

Unlimited

Unlimited

Deductible

$2,000

$2,000

Out-of-Pocket Expense Limit

$6,850 Ind/ $13,700 Family

$6,850 Ind/ $13,700 Family

Coinsurance 

80% of PA

60% of U&R

Preventive Care

100% of PA (no cost sharing)

60% of U&R

Inpatient Hospital Expense

80% of PA

60% of U&R

Physician's Office Visit

100% of PA after $25 copayment (ded. waived)

60% of U&R after $25 copayment

Urgent Care

80% of PA after $50 copayment

60% of U&R after $50 copayment

Emergency Services Expense

80% of PA after $100 copayment 

80% of PA after $100 copayment

X-Ray and Laboratory

80% of PA

60% of U&R

Prescription Drug Benefits- Prescriptions

should be filled at a Participating Cigna

Pharmacy Network 

100% of PPO Allowance after a:

- $25 Copay for Generic Drugs; or 

-$50 Copay for Preferred Brand or

-$70 Copay for Brand

                 PA= Preferred Allowance                                                                                        UR= Usual & Reasonable 

*This summary is provided as a courtesy and is not meant to replace or override the terms and conditions detailed in the insurance policy/brochure.  Please refer to the policy/brochure to verify medical coverage, eligibility, exclusions, limitations, and for more detailed information.