Medical Cigna $7,000 HDHP Base $2,000 OAP Buy-Up Network Open Access Plus Open Access Plus Plan Year Deductible Individual: $7,000 Family: $14,000 Individual: $2,000 Family: $6,000 Out-Of-Pocket Maximum Individual: $7,000 Family: $14,000 Individual: $5,000 Family: $14,700 Coinsurance 0% 20% Preventive Care visit/screening Covered in full Covered in full Office Visit Copay Primary Care: $45 Specialist: $90 Urgent Care: $75 Primary Care: $30 Specialist: $60 Urgent Care: $75 Emergency Room $500 Copay, then deductible & coinsurance $500 Copay, then deductible & coinsurance Outpatient Services Deductible & coinsurance Deductible & coinsurance Inpatient Hospital Services Deductible & coinsurance Deductible & coinsurance Prescription Copays $10 | $50 | $100 | $150 $10 | $50 | $100 | $150 Effective: October 1, 2025 Amounts shown below are your responsibility. This table only shows in-network benefits 6 www.mycigna.com | 800-997-1654