Health
Medical
We’re dang proud to offer you not one, not two…but five medical plan options, all of which offer comprehensive medical and prescription drug coverage to you and your household members. The plans also come with an entire toolkit of resources to help you live your best life. Read on to find out more about each plan.
HMO Plans
CIGNA HMO PLANS
With the HMO plans, you select a primary care physician (PCP) from the participating network of providers who will coordinate your health care needs, refer you to specialists (if needed) and approve further medical treatment. Services received outside of the HMO’s network are not covered, except in the case of emergency medical care.
Cigna Scripps Select HMO
- In-network only
- Southern CA Select (Scripps Select) Network
- Select a PCP
- Referrals required to see a specialist
Cigna Full HMO
- In-network only
- Southern CA HMO/Network
- Select a Primary Care Physician (PCP)
- Referrals required to see a specialist
KAISER PERMANENTE DEDUCTIBLE HMO PLAN
With the Kaiser HMO plan, you must use Kaiser facilities and providers for your medical and pharmacy needs. Services received outside of the Kaiser network are not covered, except in the case of emergency medical care.
- In-network only
- Kaiser health system
- No PCP required
- Specialist referrals required
SIMNSA BAJA HMO PLAN
- In-network only
- Mexican Nationals only
- Select a PCP
- Access to Non-Mexico Urgent Care
PPO Plan
CIGNA OAP PPO PLAN
The OAP PPO plan gives you the freedom to seek care from the provider of your choice. However, you will maximize your benefits and reduce your out-of-pocket costs if you choose a provider who participates in the Cigna network. The calendar-year deductible must be met before certain services are covered.
- More flexibility than an HMO
- Open Access Plus Network
- No PCP required
- No referrals required
Medical Plan Highlights
| Key Medical Benefits | Cigna Scripps Select HMO | Cigna Full HMO | Kaiser Permanente Deductible HMO | SIMNSA HMO | Cigna OAP PPO | |
|---|---|---|---|---|---|---|
| In-Network Only | In-Network Only | In-Network Only | In-Network Only | In-Network | Out-of-Network (1) | |
| Deductible (per calendar year) | ||||||
| Individual / Family | None | None | $750 / $1,500 | None | $750 / $1,500 | $1,500 / $3,000 |
| Out-of-Pocket Maximum (per calendar year) | ||||||
| Individual / Family | $2,000 / $4,000 | $3,000 / $6,000 | $3,000 / $6,000 | $6,350 / $12,700 | $2,250 / $4,500 | $4,500 / $9,000 |
| Covered Services | ||||||
| Office Visits (physician/specialist) | $20 / $40 copay | $20 / $40 copay | $25 / $25 copay | $7 copay | 10%* | 30%* |
| Routine Preventive Care | No charge | No charge | No charge | No charge | No charge | Not covered |
| Outpatient Diagnostic (lab/X-ray) | No charge | No charge | $10 copay / 20%, up to $150 per procedure | No charge | 10%* | 30%* |
| Complex Imaging | $50 copay | $200 copay | $10 copay / 20%, up to $150 per procedure | No charge | 10%* | 30%* |
| Chiropractic | $15 copay (3) | $15 copay (3) | $15 copay (3) | Not covered | 10%* (4) | 30%* |
| Acupuncture (20 visits per year) | $20 copay | Not covered | Not covered | Not covered | 10%* | 30%* |
| Ambulance | No charge | Not charge | $150 copay | No charge | 10%* | |
| Emergency Room | $100 copay waived if admitted | $150 copay waived if admitted | 20% after deductible | $250 copay | 10%* | |
| Urgent Care Facility | $25 copay | $25 copay | $25 copay | $25 copay; $50 copay out of area | 10%* | 30%* |
| Inpatient Hospital Stay | $250 copay per admission | $400 copay per admission | 20% after deductible | No charge | 10%* | 30%* |
| Outpatient Surgery | $125 copay | $400 copay | 20% after deductible | No charge | 10%* | 30%* |
| Vision Rider | $20 copay | $20 copay | Not covered | Not covered | $20 copay | Not covered |
| Prescription Drugs Generic / Brand Name / Formulary | ||||||
| Retail Pharmacy (30-day supply) | $10 / $25 / $35 | $10 / $25 / $35 | $10 / $30 / Not covered | $10 / $10 / Not covered | $10 / $30 / $50 | Not covered |
| Mail Order (90-day supply) | $20 / $50 / $70 | $20 / $50 / $70 | $20 / $60 / Not covered (100-day supply) | Not covered | $25 / $75 / $125 | Not covered |
Coinsurance percentages and copay amounts shown in the above chart represent what the member is responsible for paying.
*Benefits with an asterisk ( * ) require that the deductible be met before the plan begins to pay.
1. If you use an out-of-network provider, you will be responsible for any charges above the maximum allowed amount.
2. Pulmonary Rehabilitation, Cognitive Therapy, Physical Therapy, Speech Therapy and Occupational Therapy – Unlimited days.
3. Limited to 20 visits/year.
4. Limited to 24 visits/year.
DHMO Plans
With these plans, you choose a primary dental provider to manage your care. There are no charges for most preventive services, no claim forms and no deductibles. Reduced, pre-set charges apply to other services.
CIGNA DHMO PLAN
- In-network only
- Cigna Dental Care HMO network
- No deductible
- Includes Orthodontia coverage
SIMNSA DHMO PLAN
- Mexican Nationals only
- In-network only
- No deductible
- Includes Orthodontia coverage
PPO Plan
CIGNA DPPO
This plan offers you the freedom and flexibility to use the dentist of your choice. However, you will maximize your benefits and reduce your out-of-pocket costs if you choose a dentist who participates in the Cigna network.
- More flexibility than an HMO
- Cigna Dental PPO network
- Plan deductible applies to basic and major care
- Includes Orthodontia coverage
Dental Plan Highlights
| Key Dental Benefits | Cigna DHMO | Cigna PPO | SIMNSA DHMO | |
| In-Network Only | In-Network | Out-of-Network (1) | In-Network Only | |
| Deductible (per Calender year) | ||||
| Individual / Family | None | $50 / $150 | None | |
| Benefit Maximum (per Calender year; preventive, basic, and major Services combined) | ||||
| Per Individual | None | $1,500 per person (2) | None | |
| Covered Services | ||||
| Preventive Services | No charge | No charge | No charge | No charge |
| Basic Services | View Schedule of Benefits | 10%* | 20%* | View Schedule of Benefits |
| Major Services | View Schedule of Benefits | 40%* | 50%* | View Schedule of Benefits |
| Orthodontia (Child and Adult) | $984 child max / $1,488 adult max | 50%; $1,500 lifetime max | 50%; $1,500 lifetime max | $50 per visit |
Coinsurance percentages and copay amounts shown in the above chart represent what the member is responsible for paying.
*Benefits with an asterisk ( * ) require that the deductible be met before the Plan begins to pay.
1. When using a non-PPO (out-of-network) provider, you pay your coinsurance plus any amount over the prevailing charge, which is the price most providers in the geographic area charge for a specific service.
2. Preventive Incentive: Preventive care services do not count toward the calendar year maximum.
Vision Plan Highlights
| Key Vision Benefits | In-Network | Out-of-Network Reimbursement |
| Exam (once every 12 months) | $20 copay | $20 copay, then plan pays up to $45 |
| Materials | $20 copay | $20 copay |
| Lenses (once every 12 months) | No charge after materials copay | Up to $30 |
| Single Vision | ||
| Bifocal | Up to $50 | |
| Trifocal | Up to $65 | |
| Frames (once every 24 months) | Up to $130 plus 20% off amount over | Up to $70 |
| Contact Lenses (once every 24 months; in lieu of glasses) | Up to $150 | Up to $105 |
