CIGNA HDHP

RailWorks is pleased to offer you and your family two comprehensive medical plans through CIGNA.The plans work very differently, so please review them in detail to determine the best fit for you and your family.

CIGNA HDHP

Plan Details

Carrier

Cigna

Plan Type

HDHP

Network Name

Cigna OAP Network

Has Out Of Network Coverage

Yes

HSA Eligible

Yes

FSA Eligible

Employer Account Contribution

$600 for an individual and $1,500 for a family

Covered Services

Medical Services

	In-Network	Out-of-Network
Deductible (indiv./family)	$2,000 / $4,000	$4,000 / $8,000
Medical Out-of-Pocket Maximum (includes deductible & pharmacy)	Individual - Employee Only: $5,500 Individual - within a Family: $5,500 Family Maximum: $11,000	Individual - Employee Only: $11,000 Individual - within a Family: $11,000 Family Maximum: $22,000
Coinsurance	20% after deductible	Up to 50% after deductible
Lifetime Max. Benefit	Unlimited	Unlimited
Physician Office Visit	20% after deductible	50% after deductible
Specialist Office Visit	20% after deductible	50% after deductible
Preventive Care Services	Covered 100%, deductible waived	50% after deductible
Urgent Care Facility	20% after deductible	20% after deductible
Emergency Room	20% after deductible	20% after deductible
Inpatient Hospital Stay	20% after deductible	50% after deductible
Outpatient Services	20% after deductible	50% after deductible

Deductible (indiv./family)

In-Network: $2,000 / $4,000
Out-of-Network: $4,000 / $8,000

Medical Out-of-Pocket Maximum (includes deductible & pharmacy)

In-Network: Individual - Employee Only: $5,500 Individual - within a Family: $5,500 Family Maximum: $11,000
Out-of-Network: Individual - Employee Only: $11,000 Individual - within a Family: $11,000 Family Maximum: $22,000

Coinsurance

In-Network: 20% after deductible
Out-of-Network: Up to 50% after deductible

Lifetime Max. Benefit

In-Network: Unlimited
Out-of-Network: Unlimited

Physician Office Visit

In-Network: 20% after deductible
Out-of-Network: 50% after deductible

Specialist Office Visit

In-Network: 20% after deductible
Out-of-Network: 50% after deductible

Preventive Care Services

In-Network: Covered 100%, deductible waived
Out-of-Network: 50% after deductible

Urgent Care Facility

In-Network: 20% after deductible
Out-of-Network: 20% after deductible

Emergency Room

In-Network: 20% after deductible
Out-of-Network: 20% after deductible

Inpatient Hospital Stay

In-Network: 20% after deductible
Out-of-Network: 50% after deductible

Outpatient Services

In-Network: 20% after deductible
Out-of-Network: 50% after deductible

Prescription Drugs

	In-Network	Out-of-Network
Pharmacy Out-of-Pocket Maximum	Included in medical	Included in medical
Retail (30 days) - Generic	$15 after deductible	30% after deductible
Retail (30 days) - Preferred Brand	$40 after deductible	30% after deductible
Retail (30 days) - Non-Preferred Brand	$75 after deductible	30% after deductible
Mail (90 days) - Generic	$37.50 after deductible	In-network only
Mail (90 days) - Preferred Brand	$100 after deductible	In-network only
Mail (90 days) - Non-Preferred Brand	$187.50 after deductible	In-network only

Pharmacy Out-of-Pocket Maximum

In-Network: Included in medical
Out-of-Network: Included in medical

Retail (30 days) - Generic

In-Network: $15 after deductible
Out-of-Network: 30% after deductible

Retail (30 days) - Preferred Brand

In-Network: $40 after deductible
Out-of-Network: 30% after deductible

Retail (30 days) - Non-Preferred Brand

In-Network: $75 after deductible
Out-of-Network: 30% after deductible

Mail (90 days) - Generic

In-Network: $37.50 after deductible
Out-of-Network: In-network only

Mail (90 days) - Preferred Brand

In-Network: $100 after deductible
Out-of-Network: In-network only

Mail (90 days) - Non-Preferred Brand

In-Network: $187.50 after deductible
Out-of-Network: In-network only