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Plan Description
Cigna > Cigna Flexcare EPP
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Note: This page contains a brief summary of coverage. It does not
state all provisions and limitations of the plan. The terms and provisions of
each plan, as outlined in the plan document, will determine coverage and
eligibility.
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Broker Name:
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Cigna
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Policy Number:
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34512435
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Original Plan Effective Date:
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12/11/2002
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Rate Guarantee Expiration Date:
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12/11/2002
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Plan Anniversary Date:
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12/11/2202
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Division:
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All Divisions
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Location:
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California
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Employee Classes:
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Full Time
Manager
Officer
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In Network
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Out of Network
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General Plan Information
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Annual Deductible
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- Individual
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$500
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$1000
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- Family
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$2500
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$3000
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Coinsurance
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75%
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90%
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Office Visit/Exam
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$10 copay
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$15 copay
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Annual Out-of-Pocket Limit
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- Individual
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$1500
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$1000
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- Family
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$3000
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$2500
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Lifetime Plan Maximum
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Unlimited
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$2,000,000
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Primary Physician Election Required
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Yes
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Yes
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Preventive Services
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Well-child Care and Immunizations
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$10 copay
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$10 copay
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Adult Periodic Exams with
Preventive Tests
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$10 copay
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$10 copay
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Annual Pap or Prostate Exams
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$10 copay
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$10 copay
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Mammograms
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$10 copay
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$15 copay
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Prescription Drug Benefits
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Pharmacy/Walk-in
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- Formulary Based
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Yes
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Yes
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- Generic
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$5 copay
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$8 copay
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- Brand
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$10 copay
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$15 copay
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- Non-Formulary
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$12 copay
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$15 copay
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- Number of Days Supply
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14 days
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14 days
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- Oral Contraceptives
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$20 copay
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$25 copay
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Waiting Period Information
Eligible employees are eligible as of the 1st of the month following the
employee's hire date.
Termination of Coverage Information
When a plan participant is terminated from the company, the plan coverage ends on
the last day of the month following the employee's termination date.
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(per month)
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Employee Cost
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Company Cost
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Total
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Employee
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$6.82
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$77.16
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$83.98
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Employee + Spouse
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$24.32
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$88.60
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$112.92
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Employee + Child(ren)
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$117.31
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$45.32
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$162.63
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Family
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$154.15
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$230.21
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$384.36
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Cigna Flexcare EPP
http://www.wppo.com
Member Services
John Carpet
600 Lafayette East
Detroit, MI 48226
(313) 225-5890
Fax 345-133-4433
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Enrollment Related Form)
