Medical
Medical coverage offers healthcare protection for you and your family. You may visit any medical provider you choose, but in-network providers offer the highest level of benefits and lower out-of-pocket costs. Network providers charge members reduced, contracted fees instead of their typical fees. Providers outside the plan’s network set their own rates, so you may be responsible for the difference if a provider’s fees are above the Reasonable and Customary (R&C) limits.
Preventive Care – like physical exams, flu shots, and screenings – is always covered 100% when you use in-network providers. The key difference between the plans is the amount of money you’ll pay each pay period and when you need care.
Each plan has different:
- Annual deductible amounts – the amount you pay each year for eligible in-network and out-of-network charges before the plan begins to pay.
- Out-of-pocket maximums – the most you will pay each year for eligible network services and/or prescriptions. After you reach your out-of-pocket maximum, the plan picks up the full cost of covered medical care for the remainder of the year.
- Copays – A copay is a fixed amount you pay for a health care service. Copays do not count toward your deductible but do count toward your annual out-of-pocket maximum.
- Coinsurance – Once you’ve met your deductible, you and the plan share the cost of care, which is called coinsurance. For example, you pay 20% for services and the plan will pay 80% of the cost until you have reached your out-of-pocket maximum.
Kaiser HMO (California Employees Only)
Plan Information
Plan Name: Kaiser HMO (California Employees Only)
Policy Number: 628139
Effective Date: 11/01/2024
Provider Network: Kaiser
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
None
Out-of-Pocket Max (Individual/Family)
$2,500/$5,000
Primary Care Visit
$20 copay
Specialist Visit
$20 copay
Urgent Care
$20 copay
Emergency Room
$100 copay (waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$30 copay
Specialty
$30 copay
Mail-Order Rx (Up to 100-Day Supply)
Generic
$20 copay
Preferred Brand
$60 copay
Specialty
$60 copay; Availability for mail order varies by item
Plan Documents
Contact Information
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
In-Network
In-Network
Deductible (Individual/Family)
None
Out-of-Pocket Max (Individual/Family)
$2,500/$5,000
Primary Care Visit
$20 copay
Specialist Visit
$20 copay
Urgent Care
$20 copay
Emergency Room
$100 copay (waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$30 copay
Specialty
$30 copay
Mail-Order Rx (Up to 100-Day Supply)
Generic
$20 copay
Preferred Brand
$60 copay
Specialty
$60 copay; Availability for mail order varies by item
Plan Documents
Contact Information
Cigna OAPIN
Plan Information
Plan Name: Cigna OAPIN
Policy Number: 623494
Effective Date: 11/01/2024
Provider Network: Cigna
In-Network Benefit Highlights
Benefit Highlights
In-Network
Deductible (Individual/Family)
None
Out-of-Pocket Max (Individual/Family)
$1,500/$3,000
Preventive Care
No charge
Primary Care Visit
$20 copay
Specialist Visit
$20 copay
Urgent Care
$40 copay
Emergency Room
$100 copay (waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$25 copay
Specialty
$40 copay
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20 copay
Preferred Brand
$50 copay
Specialty
$80 copay
Plan Documents
Contact Information
PO Box 188061
Chattanooga, TN 37422-8061
(800) 494-2111
my.cigna.com
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
In-Network
In-Network
Deductible (Individual/Family)
None
Out-of-Pocket Max (Individual/Family)
$1,500/$3,000
Preventive Care
$20 copay
Primary Care Visit
$20 copay
Specialist Visit
$20 copay
Urgent Care
$40 copay
Emergency Room
$100 copay (waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$25 copay
Specialty
$40 copay
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20 copay
Preferred Brand
$50 copay
Specialty
$80 copay
Plan Documents
Contact Information
Member Services/Claims
PO Box 188061
Chattanooga, TN 37422-8061
(800) 494-2111
my.cigna.com
Cigna OAP
Plan Information
Plan Name: Cigna OAP
Policy Number: 623494
Effective Date: 11/01/2024
Provider Network: Cigna
In-Network Benefit Highlights
Benefit Highlights
In-Network
Deductible (Individual/Family)
$250/$750
Out-of-Pocket Max (Individual/Family)
$3,000/$6,000
Primary Care Visit
$20 copay
Specialist Visit
$20 copay
Urgent Care
$50 copay
Emergency Room
$100 copay
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$25 copay
Specialty
$40 copay
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20 copay
Preferred Brand
$50 copay
Specialty
$80 copay
Out-of-Network
Deductible (Individual/Family)
$750/$2,250
Out-of-Pocket Max (Individual/Family)
$6,000/$12,000
Primary Care Visit
40% after deductible
Urgent Care
40% after deductible
Emergency Room
40% after deductible
Retail Rx (Up to 30-Day Supply)
Generic
50% coinsurance (deductible waived)
Preferred Brand
50% coinsurance (deductible waived)
Specialty
50% coinsurance (deductible waived)
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not Covered
Preferred Brand
Not Covered
Specialty
Not Covered
Contact Information
PO Box 188061
Chattanooga, TN 37422-8061
(800) 494-2111
my.cigna.com
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
In-Network
Deductible (Individual/Family)
$250/$750
Out-of-Pocket Max (Individual/Family)
$3,000/$6,000
Primary Care Visit
$20 copay
Specialist Visit
$20 copay
Urgent Care
$50 copay
Emergency Room
$100 copay
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$25 copay
Specialty
$40 copay
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20 copay
Preferred Brand
$50 copay
Specialty
$80 copay
Out-of-Network
Deductible (Individual/Family)
Deductible (Individual/Family)
$750/$2,250
Out-of-Pocket Max (Individual/Family)
$6,000/$12,000
Primary Care Visit
40% after deductible
Urgent Care
40% after deductible
Emergency Room
40% after deductible
Retail Rx (Up to 30-Day Supply)
Generic
50% coinsurance (deductible waived)
Preferred Brand
50% coinsurance (deductible waived)
Specialty
50% coinsurance (deductible waived)
Mail-Order Rx (Up to 30-Day Supply)
Generic
Not Covered
Preferred Brand
Not Covered
Specialty
Not Covered
Plan Documents
Contact Information
PO Box 188061
Chattanooga, TN 37422-8061
Cigna HPHP
Plan Information
Plan Name: Cigna HDHP
Policy Number: 623494
Effective Date: 11/01/2024
Provider Network: Cigna
In-Network Benefit Highlights
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Benefit Highlights
In-Network
Deductible (Individual/Family)
$1,500/$3,000
Out-of-Pocket Max (Individual/Family)
$2,500/$5,000
Urgent Care
10% after deductible
Emergency Room
10% after deductible
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$30 copay
Non-Preferred Brand
$50 copay
Specialty
30% coinsurance up to $300 maximum payment per prescription
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20 copay
Preferred Brand
$60 copay
Non-Preferred Brand
$100 copay
Specialty
30% coinsurance up to $300 maximum payment per prescription (maximum 30 day supply)
Out-of-Network
Deductible (Individual/Family)
$1,500/$3,000
Out-of-Pocket Max (Individual/Family)
$5,000/$10,000
Urgent Care
30% after deductible
Emergency Room
10% after deductible
Retail Rx (Up to 30-Day Supply)
Generic
Not Covered
Preferred Brand
Not Covered
Specialty
Not Covered
Mail-Order Rx (Up to 30-Day Supply)
Generic
Not Covered
Preferred Brand
Not Covered
Specialty
Not Covered
Plan Documents
Contact Information
PO Box 188061
Chattanooga, TN 37422-8061
(800) 494-2111
my.cigna.com
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
In-Network
Deductible (Individual/Family)
$1,500/$3,000
Out-of-Pocket Max (Individual/Family)
$2,500/$5,000
Urgent Care
10% after deductible
Emergency Room
10% after deductible
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$30 copay
Non-Preferred Brand
$50 copay
Specialty
30% coinsurance up to $300 maximum payment per prescription
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20 copay
Preferred Brand
$60 copay
Non-Preferred Brand
$100 copay
Specialty
30% coinsurance up to $300 maximum payment per prescription (maximum 30 day supply)
Out-of-Network
Deductible (Individual/Family)
$1,500/$3,000
Out-of-Pocket Max (Individual/Family)
$5,000/$10,000
Urgent Care
30% after deductible
Emergency Room
10% after deductible
Retail Rx (Up to 30-Day Supply)
Generic
Not Covered
Preferred Brand
Not Covered
Specialty
Not Covered
Mail-Order Rx (Up to 30-Day Supply)
Generic
Not Covered
Preferred Brand
Not Covered
Specialty
Not Covered
Plan Documents
Contact Information
Member Services/Claims
PO Box 188061
Chattanooga, TN 37422-8061
(800) 494-2111
my.cigna.com