Cigna HDHP

Lowest cost option for your health care coverage and paired with HSA

Cigna HDHP

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Plan Details

Carrier

Cigna

Network Name

Cigna

Plan Type

HDHP

HSA Eligible

Yes

FSA Eligible

HRA Included

Premiums

Frequency: Biweekly

Coverage Tier	With LiveWell Credit	Without LiveWell Credit
EE Only	$34.00	$68.62
EE + Children	$66.00	$100.62
EE + Spouse	$83.00	$117.62
EE + Family	$113.00	$147.62

EE Only

With LiveWell Credit: $34.00
Without LiveWell Credit: $68.62

EE + Children

With LiveWell Credit: $66.00
Without LiveWell Credit: $100.62

EE + Spouse

With LiveWell Credit: $83.00
Without LiveWell Credit: $117.62

EE + Family

With LiveWell Credit: $113.00
Without LiveWell Credit: $147.62

Deductible, Out-of-Pocket & Coinsurance

Feature	Network	NON-Network
Deductible (Individual)	$1,700	$3,400
Deductible (Family)	$3,400	$6,800
Out-of-Pocket Max (Individual)	$3,500	$7,000
Out-of-Pocket Max (Family)	$7,000	$14,000
Employer Contribution - Per Individual	$800 (prorated ER contribution)	$800 (prorated ER contribution)
Employer Contribution - Per Family	$1,600 (prorated ER contribution)	$1,600 (prorated ER contribution)

Deductible (Individual)

Network: $1,700
NON-Network: $3,400

Deductible (Family)

Network: $3,400
NON-Network: $6,800

Out-of-Pocket Max (Individual)

Network: $3,500
NON-Network: $7,000

Out-of-Pocket Max (Family)

Network: $7,000
NON-Network: $14,000

Employer Contribution - Per Individual

Network: $800 (prorated ER contribution)
NON-Network: $800 (prorated ER contribution)

Employer Contribution - Per Family

Network: $1,600 (prorated ER contribution)
NON-Network: $1,600 (prorated ER contribution)

Covered Services

Service	Network	NON-Network
Preventive Care	100% covered	40%*
LW Clinic Visit	$25 copayment	N/A
Office Visits	20%*	40%*
Specialist Office Visits	20%*	40%*
Outpatient Surgery	20%*	40%*
Hospitalization and Inpatient Surgery	20%*	40%*
Mental Health	20%*	40%*
Virtual visits	$0 copayment	N/A
Urgent Care Facility	20%*	40%*
Emergency Room	20%*	20%*
Ambulance	20%*	20%*

Preventive Care

Network: 100% covered
NON-Network: 40%*

LW Clinic Visit

Network: $25 copayment
NON-Network: N/A

Office Visits

Network: 20%*
NON-Network: 40%*

Specialist Office Visits

Network: 20%*
NON-Network: 40%*

Outpatient Surgery

Network: 20%*
NON-Network: 40%*

Hospitalization and Inpatient Surgery

Network: 20%*
NON-Network: 40%*

Mental Health

Network: 20%*
NON-Network: 40%*

Virtual visits

Network: $0 copayment
NON-Network: N/A

Urgent Care Facility

Network: 20%*
NON-Network: 40%*

Emergency Room

Network: 20%*
NON-Network: 20%*

Ambulance

Network: 20%*
NON-Network: 20%*

* After deductible

Pharmacy Benefits

Tier	Channel	Cost
Tier 1 Generic Drugs	Retail Rx (up to 30-day supply)	$5 copayment
Tier 2 Brand-name drugs (on the Preferred Drug List)	Retail Rx (up to 30-day supply)	$30 copayment
Tier 3 Brand-name drugs (not on the Preferred Drug List)	Retail Rx (up to 30-day supply)	$60 copayment
Tier 4 Specialty retail drugs (injection, infused or oral)	Retail Rx (up to 30-day supply)	$100 copayment (30-day supply)
Tier 1 Generic Drugs	Mail Order Rx (31 to 90-day supply)	$10 copayment
Tier 2 Brand-name drugs (on the Preferred Drug List)	Mail Order Rx (31 to 90-day supply)	$60 copayment
Tier 3 Brand-name drugs (not on the Preferred Drug List)	Mail Order Rx (31 to 90-day supply)	$120 copayment
Tier 4 Specialty mail order drugs (injection, infused or oral)	Mail Order Rx (31 to 90-day supply)	$100 copayment (30-day supply)

Tier 1 Generic Drugs

Channel: Retail Rx (up to 30-day supply)
Cost: $5 copayment

Tier 2 Brand-name drugs (on the Preferred Drug List)

Channel: Retail Rx (up to 30-day supply)
Cost: $30 copayment

Tier 3 Brand-name drugs (not on the Preferred Drug List)

Channel: Retail Rx (up to 30-day supply)
Cost: $60 copayment

Tier 4 Specialty retail drugs (injection, infused or oral)

Channel: Retail Rx (up to 30-day supply)
Cost: $100 copayment (30-day supply)

Tier 1 Generic Drugs

Channel: Mail Order Rx (31 to 90-day supply)
Cost: $10 copayment

Tier 2 Brand-name drugs (on the Preferred Drug List)

Channel: Mail Order Rx (31 to 90-day supply)
Cost: $60 copayment

Tier 3 Brand-name drugs (not on the Preferred Drug List)

Channel: Mail Order Rx (31 to 90-day supply)
Cost: $120 copayment

Tier 4 Specialty mail order drugs (injection, infused or oral)

Channel: Mail Order Rx (31 to 90-day supply)
Cost: $100 copayment (30-day supply)

Plan Notes

Pharmacy benefits are administered through Cigna and Express Scripts.
Preventive drug costs may be $0 cost to you.
Home delivery through Express Scripts Pharmacy — enroll at mycigna.com or myCigna app or call 800-835-3784.
Preventive Medication Program: Medications covered for chronic health conditions at a $0 copayment. Call 800-244-6224.
Prior Authorization Program: Requires prior authorization for certain medications.
Step Therapy Program: Requires you to try a proven, cost-effective medication before a more costly treatment.