Medical Provider: Cigna
Group #00629701
Member Service: (800) 244-6224
Website: www.mycigna.com
Prescription Drugs Provider: Cigna
Website: www.mycigna.com
Northwest Georgia Oncology Centers offers comprehensive medical and prescription benefits for you and your family. Detailed benefit summaries, SPDs, and plan documents can be found in the menu.
The following table is a general overview of your Medical Benefits and Deductible requirements. Please refer to your Detail Benefit Summary or call customer service for specific benefit details, limitations, and/or exclusions.
OAP Plan Features
| Benefit | In-Network | Out-of-Network |
|---|---|---|
| Deductible (Single / Family) | $1,000 / $3,000 | $1,500 / $4,500 |
| Out-of-Pocket Maximum (Single / Family) | $2,000 / $4,000 | $3,000 / $9,000 |
| Primary Care Visit (PCP) | $25 copay |
30% after deductible |
| Specialist Visit | $50 copay | 30% after deductible |
| Preventive Care | No Charge | 30% after deductible |
| Emergency Room | $200 copay | $200 copay |
| Urgent Care | $75 copay | $75 copay |
| Inpatient | 0% after deductible | 30% after deductible |
| Outpatient | 0% after deductible | 30% after deductible |
| Prescription Retail (31 days) | Generic: $10 copay | Generic: N/A |
| Preferred brand: $25 copay | Preferred brand: N/A | |
| Non-preferred brand: $50 copay | Non-preferred brand: N/A | |
| Prescription Mail Order (90 days) | Generic: $30 copay | Generic: N/A |
| Preferred brand: $75 copay | Preferred brand: N/A | |
| Non-preferred brand: $150 copay | Non-preferred brand: N/A |
HDHP Plan Features
| Benefit | In-Network | Out-of-Network |
|---|---|---|
| Deductible (Single / Family) | $2,500 / $5,000 | $5,000 / $10,000 |
| Out-of-Pocket Maximum (Single / Family) | $5,000 / $10,000 | $10,000 / $20,000 |
| Primary Care Visit (PCP) | 20% after deductible |
40% after deductible |
| Specialist Visit | 20% after deductible | 40% after deductible |
| Preventive Care | Covered 100% | 40% after deductible |
| Emergency Room | 20% after deductible | 20% after deductible |
| Urgent Care | 20% after deductible | 20% after deductible |
| Inpatient | 20% after deductible | 40% after deductible |
| Outpatient | 20% after deductible | 40% after deductible |
| Prescription Retail (31 days) | Generic: $15 copay | Generic: N/A |
| Preferred brand: $30 copay | Preferred brand: N/A | |
| Non-preferred brand: $60 copay | Non-preferred brand: N/A | |
| Prescription Mail Order (90 days) | Generic: $45 copay | Generic: N/A |
| Preferred brand: $90 copay | Preferred brand: N/A | |
| Non-preferred brand: $180 copay | Non-preferred brand: N/A |
Note: Prescription Copays apply after medical deductible is met
Bi-weekly Deduction Amounts
| Point of Service Plan | Payroll Deductions |
| Employee Only | $52.00 |
| Employee + Spouse | $147.00 |
| Employee + Child(ren) | $152.00 |
| Employee + Family | $235.00 |
| High Deductible Health Plan | Payroll Deductions |
| Employee Only | $30.00 |
| Employee + Spouse | $85.00 |
| Employee + Child(ren) | $90.00 |
| Employee + Family | $150.00 |
