| Annual Deductible | $3,500 Ind / $7,000 Fam | $5,000 Ind / $10,000 Fam | $7,500 Ind / $15,000 Fam | $8,500 Ind / $17,000 Fam | $10,000 Ind / $20,000 Fam |
| Annual Out-of-Pocket Max | $7,000 Ind / $14,000 Fam | $10,000 Ind / $20,000 Fam | $10,000 Ind / $20,000 Fam | $8,500 Ind / $17,000 Fam | $10,000 Ind / $20,000 Fam |
| Preventive Care Screening | No Cost | No Cost | No Cost | No Cost | No Cost |
| Primary Care Visit | $25 copay | $25 copay | $50 copay | No cost after deductible | $50 copay |
| Specialist Visit | $50 copay | $75 copay | $100 copay | No cost after deductible | $100 copay |
| Urgent Care Visit | $75 copay | $100 copay | $100 copay | No cost after deductible | $100 copay |
| Emergency Room | Deductible, then 20% coins. | Deductible, then 30% coins. | Deductible, then 30% coins. | No cost after deductible | No cost after deductible |
| Outpatient Services | Deductible, then 20% coins. | Deductible, then 30% coins. | Deductible, then 30% coins. | No cost after deductible | No cost after deductible |
| Inpatient Services | Deductible, then 20% coins. | Deductible, then 30% coins. | Deductible, then 30% coins. | No cost after deductible | No cost after deductible |
| Pharmacy | $0 copay (Generic, Brand, Ltd. Specialty) | $0 copay (Generic, Brand, Ltd. Specialty) | $0 copay (Generic, Brand, Ltd. Specialty) | $0 copay (Generic, Brand, Ltd. Specialty) | $0 copay (Generic, Brand, Ltd. Specialty) |
| Telehealth | Yes | Yes | Yes | Yes | Yes |
| CareGuide Advocate | Yes | Yes | Yes | Yes | Yes |
| Provider Network | Cigna PPO | Cigna PPO | Cigna PPO | Cigna PPO | Cigna PPO |