CIGNA Open Access Coinsurance Plus Choice Fund HRA

HRA Reimbursement Request Form

The plan summary provides a detailed listing of care options and coverages.

General coverages are listed here for a quick overview.

In-Network options and coverages are as follows: 

Deductible $1,250/$2,500
Coinsurance 90% after deductible
Physician Copay 90% after deductible
Preventive Office Copay
 Covered 100%
Outpatient Copay 90% after deductible
Inpatient Copay 90% after deductible
Home Health Care 90% after deductible
Emergency Care 90% after deductible
Urgent Care 90% after deductible
Retail Prescriptions $10/$25/$40 copay
Mail Order Prescriptions 
(90-day supply)		 $20/$50/$80 copay
Enhanced Preventive Drugs N/A
Mental Health (MH) /
Substance Abuse (SA) 		 
MH/SA Inpatient Facility Svcs
 90% after deductible
MH/SA Outpatient Facility Svcs 90% after deductible
MH/SA Outpatient Svcs 90% after deductible
Routine Vision Exam
(Every 24 months)
 Covered 100%
Max Out-Of-Pocket $2,750/$5,500

Out-of-Network options and coverages are as follows:

Deductible $1,250/$2,500
Coinsurance 70% after deductible
Physician Copay 70% after deductible
Preventive Office Copay
 70% after deductible
Outpatient Copay 70% after deductible
Inpatient Copay 70% after deductible
Home Health Care 70% after deductible
Emergency Care 90% after deductible
Urgent Care 90% after deductible
Prescriptions

IN NETWORK
COVERAGE ONLY
Mental Health (MH) /
Substance Abuse (SA) 		 
MH/SA Inpatient Facility Svcs
 70% after deductible
MH/SA Outpatient Facility Svcs 70% after deductible
MH/SA Outpatient Svcs 70% after deductible
Routine Vision Exam
(Every 24 months)
 $45
Max Out-Of-Pocket $2,750/$5,500