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.
Cigna $500 Gold PPO
Plan Information
Plan Name: Cigna $500 Gold PPO
Policy Number: 0635940
Effective Date: 01/01/2025
Provider Network: Open Access Plus (OAP)
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)
$500/$1,500
Out-of-Pocket Max (Individual/Family)
$3,500/$7,000
Preventive Care
$0
Primary Care Visit
$20 copay
Specialist Visit
$20 copay
Urgent Care
$25 copay
Emergency Room
$150 copay + 20%* (copay waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
$5 copay
Brand
$25 copay
Non-Formulary
$40 copay
Specialty
$45 copay
Mail-Order Rx (Up to 90-Day Supply)
Generic
$10 copay
Brand
$50 copay
Non-Formulary
$80 copay
Specialty
$45 copay for 30-day supply
Out-of-Network
Deductible (Individual/Family)
$500/$1,500
Out-of-Pocket Max (Individual/Family)
$7,000/$14,000
Preventive Care
40%*
Primary Care Visit
40%*
Specialist Visit
40%*
Urgent Care
40%*
Emergency Room
$150 copay + 20%* (copay waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
50%
Brand
50%
Non-Formulary
50%
Specialty
50%
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Brand
Not covered
Non-Formulary
Not covered
Specialty
Not covered
* After deductible
Plan Documents
Contact Information
Cigna $250 Platinum PPO
Plan Information
Plan Name: Cigna $250 Platinum PPO
Policy Number: 0635940
Effective Date: 01/01/2025
Provider Network: Open Access Plus (OAP)
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)
$250/$750*
Out-of-Pocket Max (Individual/Family)
$2,250/$4,500
Preventive Care
$0
Primary Care Visit
$20 copay
Specialist Visit
$20 copay
Urgent Care
$25 copay
Emergency Room
$150 copay + 10%* (copay waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
$5 copay
Brand
$25 copay
Non-Formulary
$40 copay
Specialty
$45 copay
Mail-Order Rx (Up to 90-Day Supply)
Generic
$10 copay
Brand
$50 copay
Non-Formulary
$80 copay
Specialty
$45 copay for 30-day supply
Out-of-Network
Deductible (Individual/Family)
$250/$750*
Out-of-Pocket Max (Individual/Family)
$6,500/$13,000
Preventive Care
30%**
Primary Care Visit
30%**
Specialist Visit
30%**
Urgent Care
30%**
Emergency Room
$150 copay + 10%** (copay waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
50%
Brand
50%
Non-Formulary
50%
Specialty
50%
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Brand
Not covered
Non-Formulary
Not covered
Specialty
Not covered
* Combined for In-Network and Out-of-Network
** After deductible
Plan Documents
Contact Information
Kaiser HMO
Plan Information
Plan Name: Kaiser HMO
Policy Number: 729173
Effective Date: 01/01/2025
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 Only
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$1,500/$3,000
Preventive Care
$0
Primary Care Visit
$15 copay
Specialist Visit
$15 copay
Urgent Care
$15 copay
Emergency Room
$200 copay (waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Brand
$30 copay
Specialty
20% up to $250
Mail-Order Rx (Up to 100-Day Supply)
Generic
$20 copay
Brand
$60 copay
Specialty
Not covered
Plan Documents
Contact Information
See your ID card for the appropriate Kaiser contact