Medical
Medical coverage offers healthcare protection for you and your family. You may visit any medical provider you choose, but in-network providers offer the highest level of benefits and lower out-of-pocket costs. Network providers charge members reduced, contracted fees instead of their typical fees. Providers outside the plan’s network set their own rates, so you may be responsible for the difference if a provider’s fees are above the Reasonable and Customary (R&C) limits.
Preventive Care – like physical exams, flu shots, and screenings – is always covered 100% when you use in-network providers. The key difference between the plans is the amount of money you’ll pay each pay period and when you need care.
Each plan has different:
- Annual deductible amounts – the amount you pay each year for eligible in-network and out-of-network charges before the plan begins to pay.
- Out-of-pocket maximums – the most you will pay each year for eligible network services and/or prescriptions. After you reach your out-of-pocket maximum, the plan picks up the full cost of covered medical care for the remainder of the year.
- Copays – A copay is a fixed amount you pay for a health care service. Copays do not count toward your deductible but do count toward your annual out-of-pocket maximum.
- Coinsurance – Once you’ve met your deductible, you and the plan share the cost of care, which is called coinsurance. For example, you pay 20% for services and the plan will pay 80% of the cost until you have reached your out-of-pocket maximum.
Cigna HDHP
Plan Information
Plan Name: Cigna HDHP
Policy Number: 633468
Effective Date: 01/01/2025
Provider Network: Cigna Open Access Plus (OAP) – Non-Utah Employees; Cigna PPO – Utah Employees
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$1,650/$3,300
Out-of-Pocket Max (Individual/Family)
$4,000/$8,000
Preventive Care
$0
Primary Care Visit
10% coinsurance after deductible
Specialist Visit
10% coinsurance after deductible
Urgent Care
10% coinsurance after deductible
Emergency Room
$250 copay and 10% coinsurance after deductible
Retail Rx (Up to 30-Day Supply)
Generic
$10 after deductible
Preferred Brand
$35 after deductible
Non-Preferred Brand
$70 after deductible
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20 copay after deductible
Preferred Brand
$70 copay after deductible
Non-Preferred Brand
$140 copay after deductible
Out-of-Network
Deductible (Individual/Family)
$4,500/$8,400
Out-of-Pocket Max (Individual/Family)
$10,500/$15,000
Preventive Care
30% coinsurance after deductible
Primary Care Visit
30% coinsurance after deductible
Specialist Visit
30% coinsurance after deductible
Urgent Care
30% coinsurance after deductible
Emergency Room
$250 copay and 10% coinsurance after deductible
Retail Rx (Up to 30-Day Supply)
Generic
Not Covered
Preferred Brand
Not Covered
Non-Preferred Brand
Not Covered
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not Covered
Preferred Brand
Not Covered
Non-Preferred Brand
Not Covered
Plan Documents
Contact Information
Cigna PPO
Plan Information
Plan Name: Cigna PPO
Policy Number: 633468
Effective Date: 01/01/2025
Provider Network: Cigna Open Access Plus (OAP Network) – Non-Utah Employees; Cigna Preferred Provider Organization (PPO Network) – Utah Employees
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$500/$1,000
Out-of-Pocket Max (Individual/Family)
$4,000/$8,000
Preventive Care
$0
Primary Care Visit
$25 copay
Specialist Visit
$25 copay
Urgent Care
$50 copay
Emergency Room
$250 copay and 10% coinsurance after deductible
Retail Rx (Up to 30-Day Supply)
Generic
$15 copay
Preferred Brand
$35 copay
Non-Preferred Brand
$70 copay
Mail-Order Rx (Up to 90-Day Supply)
Generic
$30 copay, deductible does not apply
Preferred Brand
$70 copay, deductible does not apply
Non-Preferred Brand
$140 copay, deductible does not apply
Out-of-Network
Deductible (Individual/Family)
$1,500/$3,000
Out-of-Pocket Max (Individual/Family)
$10,500/$21,000
Preventive Care
30% coinsurance after deductible
Primary Care Visit
30% coinsurance after deductible
Specialist Visit
30% coinsurance after deductible
Urgent Care
30% coinsurance after deductible
Emergency Room
$250 copay and 10% coinsurance after deductible
Retail Rx (Up to 30-Day Supply)
Generic
Not Covered
Preferred Brand
Not Covered
Non-Preferred Brand
Not Covered
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not Covered
Preferred Brand
Not Covered
Non-Preferred Brand
Not Covered
Plan Documents
Contact Information
Cigna HMO
Plan Information
Plan Name: Cigna HMO
Policy Number: 633468
Effective Date: 01/01/2025
Provider Network: Cigna Open Access Plus (OAP Network) – Non-Utah Employees; Cigna Preferred Provider Organization (PPO Network) – Utah Employees
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$1,500/$3,000
Preventive Care
$0
Primary Care Visit
$20 copay
Specialist Visit
$35 copay
Urgent Care
$50 copay
Emergency Room
$250 copay and 10% coinsurance after deductible
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$30 copay
Non-Preferred Brand
$50 copay
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20 copay
Preferred Brand
$60 copay
Non-Preferred Brand
$100 copay
Plan Documents
Contact Information
Kaiser HMO (CA)
Plan Information
Plan Name: Kaiser HMO (CA)
Policy Number: 607163
Effective Date: 01/01/2025
Provider Network: Kaiser Permanente
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$1,500/$3,000
Preventive Care
$0
Primary Care Visit
$20 copay
Specialist Visit
$35 copay
Urgent Care
$20 copay
Emergency Room
$100 copay (waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
$10
Preferred Brand
$35
Specialty
20% coinsurance with $150 max
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20
Preferred Brand
$50
Plan Documents
Contact Information
Kaiser HMO (GA)
Plan Information
Plan Name: Kaiser HMO (GA)
Policy Number: 10691
Effective Date: 01/01/2025
Provider Network: Kaiser
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$1,500/$3,000
Preventive Care
$0
Primary Care Visit
$20 copay
Specialist Visit
$30 copay
Urgent Care
$30 copay
Emergency Room
$100 copay (waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
$10
Preferred Brand
$35
Non-Preferred Brand
$40
Specialty
20% coinsurance, up to $150
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20
Preferred Brand
$70
Specialty
Not covered
Plan Documents
Contact Information
Kaiser HMO (HI)
Plan Information
Plan Name: Kaiser HMO (HI)
Policy Number: 17722
Effective Date: 01/01/2025
Provider Network: Kaiser
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$2,500/$7,500
Preventive Care
$0
Primary Care Visit
$15 copay
Specialist Visit
$15 copay
Urgent Care
$15 copay
Emergency Room
$75 copay (waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
$10
Preferred Brand
$35
Non-Preferred Brand
$35
Specialty
$200
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20
Preferred Brand
$70
Non-Preferred Brand
$70
Specialty
Not covered