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Member Summary For:
John Doe
Relationship: EMPLOYEE
Date of Birth: 01/01/1970
Product: CIGNA Choice Fund
Pharmacy Product: Tier 3
Account No: 1234567
Effective Date: 01/01/2002
Eligibility Status: Active
Current Physician: SMITH DAVID MD
 
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Below are benefit plan highlights for: John Doe

Please review your plan documents for full details, including exclusions, limitations and state mandates that might affect the benefits described below.

DeductiblesIn-Network Out-of-Network
Individual $2,000.00 $2,500.00
Family $4,000.00 $5,000.00
Member's Coinsurance Percents In-Network Out-of-Network
Office Visit 20% 40%
Specialist Office Visit 20% 40%
Pharmacy ServicesGenericPreferred BrandNon-Preferred
Brand
Retail Copay (30 Day Supply)$10.00$30.00$ 50.00
Mail Order Copay (90 Day Supply)$20.00$60.00$100.00
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