Choate House on the Pace Pleasantville campus

Choice PPO Plan

(January 1, 2021 through December 31, 2021)

The Choice PPO plan, offers both in- and out-of-network coverage. This plan introduces a deductible and coinsurance for both in- and out-of-network services.

In-Network Benefits

  • Co-payments of $30 to see a Primary Care Physician and $50 to see a Specialist. No referrals are needed.
  • In-network mental health and substance abuse outpatient visits are covered at the primary office visit copayment ($30). Previously, these services were covered at the specialist office visit copayment ($50).
  • Preventive care exams (PDF) are covered at 100%.
  • All services beyond a regular office visit , including lab work performed at an in-network independent lab, is subject first to a $750 calendar year deductible for individual coverage, $1,500 calendar year deductible for employee + 1 and family coverage, then 15% member co-insurance. This includes lab work and x-ray s performed at an outpatient hospital facility, outpatient surgery, and inpatient hospitalization.
  • $85 Emergency Room co-payment, which is waived if you (or a covered dependent ) are admitted to the hospital.
  • The calendar year (in-network) Out-of-Pocket Maximum is $2,000 for an individual and $4,000 for employee + 1 and family coverage.
  • In-network prescription co-payments of: $20 for generic medications, $45 for preferred brand medications, and $70 for non-preferred brand medications, after the calendar year deductible for non-generic prescriptions ($125 per person, $375 for +1 and family) has been satisfied. $0 co-payments for generic preventive medications on this list (PDF).
  • Please review the Cigna Value 3-Tier Prescription Drug List (PDF), especially the section entitled, “Medications That Are Not Covered” (beginning on Page 18).

Out-of-Network Benefits

  • The calendar year deductible is $2,000 for individual coverage and $4,000 for employee + 1 and family coverage.
  • After the (calendar year) deductible is met, all services are subject to 35% employee co-insurance, until the Out-of-Pocket Maximum is reached.
  • The annual (calendar year) Out-of-Pocket Maximum, which is based on 300% of Medicare rates, is $5,000 for individual coverage and $10,000 for employee + 1 and family coverage. For out-of-network providers, you may, in fact, pay more than the Out-of-Pocket Maximum if your provider charges rates that are above the 300% of Medicare guidelines.
  • In most cases, for out-of-network services, employees pay in advance for services and submit a claim form to Cigna Healthcare. All claim forms are located on the Human Resources web page under "Forms."