Cigna PPO Open Access Plan

Your medical benefits are provided by Cigna and include coverage for both in-network and out-of-network providers.

Premiums are calculated on 24 pay periods and deducted from the first two paychecks of each month.

Coverage Tier	Total Monthly Premium	Modera’s Monthly Contribution	Employee Monthly Premium	Employee Payroll Deduction per Pay Period
Employee	$1,524.76	$1,524.76	$0.00	$0.00
Employee + Spouse	$3,037.00	$2,280.88	$756.12	$378.06
Employee + Child(ren)	$2,792.21	$2,158.49	$633.73	$316.86
Family	$4,240.32	$2,882.54	$1,357.78	$678.89

Employee

Employee + Spouse

Employee + Child(ren)

Family

Service	In-Network Benefits
Annual Deductible	$1,000 per individual / $2,000 per family
Coinsurance (plan pays)	80%
Out of Pocket Maximum*	$3,000 per individual / $6,000 per family
Preventive Care	Covered at 100%
Office Visit	PCP: $25 copay / Specialist: $40 copay / Urgent Care: $40 copay
Emergency Room	$200 copay
Inpatient Hospital	Deductible and coinsurance
Outpatient Surgery	Deductible and coinsurance

Annual Deductible

Coinsurance (plan pays)

Out of Pocket Maximum*

Preventive Care

Office Visit

In-Network Benefits: PCP: $25 copay / Specialist: $40 copay / Urgent Care: $40 copay

Emergency Room

Inpatient Hospital

Outpatient Surgery

	In-Network Benefits
Prescription Drugs	Tier 1: $25 / Tier 2: $50 / Tier 3: $75 / Mail Order: 3x retail (a prescription filled by mail costs three times what you would pay at a regular retail pharmacy)

Prescription Drugs

In-Network Benefits: Tier 1: $25 / Tier 2: $50 / Tier 3: $75 / Mail Order: 3x retail (a prescription filled by mail costs three times what you would pay at a regular retail pharmacy)

The PPO may be a fit if you prefer set copays for office visits and prescriptions instead of paying the full cost until a deductible is met, and want to know what you will pay at the time you receive care.
For surgery, you pay the $1,000 deductible, then the plan pays 80%.
In-network services are based on negotiated charges; Out-of-network services are based on 110% of a Cigna fee schedule that uses Medicare’s pricing method.