Cigna HDHP
The HDHP is the lowest cost option for your health care coverage.
Cigna HDHP
Plan Details
- Carrier
- Cigna
- Plan Type
- HDHP
- Network
- Cigna
- HSA Eligible
- Yes
- HRA Included
- No
EE Only
- Monthly Premium
- $918.25
EE + Children
- Monthly Premium
- $1,926.15
EE + Spouse
- Monthly Premium
- $2,291.11
EE + Family
- Monthly Premium
- $3,311.26
| Coverage Tier | Monthly Premium |
|---|---|
| EE Only | $918.25 |
| EE + Children | $1,926.15 |
| EE + Spouse | $2,291.11 |
| EE + Family | $3,311.26 |
DFW Contributions - Per Individual
- Network
- $800 (prorated ER contribution)
- Non-Network
- $800 (prorated ER contribution)
DFW Contributions - Per Family
- Network
- $1,600 (prorated ER contribution)
- Non-Network
- $1,600 (prorated ER contribution)
Annual Deductible (Excludes Prescription Copayments) - Per Individual
- Network
- $1,700
- Non-Network
- $3,400
Annual Deductible (Excludes Prescription Copayments) - Per Family
- Network
- $3,400
- Non-Network
- $6,800
Annual Out-of-Pocket Limit (Includes the Deductible, Copays, and Coinsurance) - Per Individual
- Network
- $3,500
- Non-Network
- $7,000
Annual Out-of-Pocket Limit (Includes the Deductible, Copays, and Coinsurance) - Per Family
- Network
- $7,000
- Non-Network
- $14,000
Coinsurance/Copayments - Preventive Care
- Network
- 100% covered
- Non-Network
- 40%*
Coinsurance/Copayments - LW Clinic Visit
- Network
- $25 copayment
- Non-Network
- N/A
Coinsurance/Copayments - Office Visits
- Network
- 20%*
- Non-Network
- 40%*
Coinsurance/Copayments - Specialist Office Visits
- Network
- 20%*
- Non-Network
- 40%*
Coinsurance/Copayments - Outpatient Surgery
- Network
- 20%*
- Non-Network
- 40%*
Coinsurance/Copayments - Hospitalization and Inpatient Surgery
- Network
- 20%*
- Non-Network
- 40%*
Coinsurance/Copayments - Mental Health (Inpatient/Outpatient)
- Network
- 20%*
- Non-Network
- 40%*
Coinsurance/Copayments - Virtual visits powered by MDLive Medical and Behavioral Mental Health
- Network
- $0 copayment
- Non-Network
- N/A
Coinsurance/Copayments - Urgent Care Facility
- Network
- 20%*
- Non-Network
- 40%*
Coinsurance/Copayments - Emergency Room
- Network
- 20%*
- Non-Network
- 20%*
Coinsurance/Copayments - Ambulance
- Network
- 20%*
- Non-Network
- 20%*
| Benefit | Network | Non-Network |
|---|---|---|
| DFW Contributions - Per Individual | $800 (prorated ER contribution) | $800 (prorated ER contribution) |
| DFW Contributions - Per Family | $1,600 (prorated ER contribution) | $1,600 (prorated ER contribution) |
| Annual Deductible (Excludes Prescription Copayments) - Per Individual | $1,700 | $3,400 |
| Annual Deductible (Excludes Prescription Copayments) - Per Family | $3,400 | $6,800 |
| Annual Out-of-Pocket Limit (Includes the Deductible, Copays, and Coinsurance) - Per Individual | $3,500 | $7,000 |
| Annual Out-of-Pocket Limit (Includes the Deductible, Copays, and Coinsurance) - Per Family | $7,000 | $14,000 |
| Coinsurance/Copayments - Preventive Care | 100% covered | 40%* |
| Coinsurance/Copayments - LW Clinic Visit | $25 copayment | N/A |
| Coinsurance/Copayments - Office Visits | 20%* | 40%* |
| Coinsurance/Copayments - Specialist Office Visits | 20%* | 40%* |
| Coinsurance/Copayments - Outpatient Surgery | 20%* | 40%* |
| Coinsurance/Copayments - Hospitalization and Inpatient Surgery | 20%* | 40%* |
| Coinsurance/Copayments - Mental Health (Inpatient/Outpatient) | 20%* | 40%* |
| Coinsurance/Copayments - Virtual visits powered by MDLive Medical and Behavioral Mental Health | $0 copayment | N/A |
| Coinsurance/Copayments - Urgent Care Facility | 20%* | 40%* |
| Coinsurance/Copayments - Emergency Room | 20%* | 20%* |
| Coinsurance/Copayments - Ambulance | 20%* | 20%* |
- * After deductible
Retail Rx (up to 30-day supply)
- You Pay
Retail Rx - Tier 1 Generic Drugs
- You Pay
- $5 copayment
Retail Rx - Tier 2 Brand-name drugs (on the Preferred Drug List)
- You Pay
- $30 copayment
Retail Rx - Tier 3 Brand-name drugs (not on the Preferred Drug List)
- You Pay
- $60 copayment
Retail Rx - Tier 4 Specialty retail drugs (injection, infused or oral)
- You Pay
- $100 copayment (30-day supply)
Mail Order Rx (31 to 90-day supply)
- You Pay
Mail Order Rx - Tier 1 Generic Drugs
- You Pay
- $10 copayment
Mail Order Rx - Tier 2 Brand-name drugs (on the Preferred Drug List)
- You Pay
- $60 copayment
Mail Order Rx - Tier 3 Brand-name drugs (not on the Preferred Drug List)
- You Pay
- $120 copayment
Mail Order Rx - Tier 4 Specialty mail order drugs (injection, infused or oral)
- You Pay
- $100 copayment (30-day supply)
| Tier | You Pay |
|---|---|
| Retail Rx (up to 30-day supply) | |
| Retail Rx - Tier 1 Generic Drugs | $5 copayment |
| Retail Rx - Tier 2 Brand-name drugs (on the Preferred Drug List) | $30 copayment |
| Retail Rx - Tier 3 Brand-name drugs (not on the Preferred Drug List) | $60 copayment |
| Retail Rx - Tier 4 Specialty retail drugs (injection, infused or oral) | $100 copayment (30-day supply) |
| Mail Order Rx (31 to 90-day supply) | |
| Mail Order Rx - Tier 1 Generic Drugs | $10 copayment |
| Mail Order Rx - Tier 2 Brand-name drugs (on the Preferred Drug List) | $60 copayment |
| Mail Order Rx - Tier 3 Brand-name drugs (not on the Preferred Drug List) | $120 copayment |
| Mail Order Rx - Tier 4 Specialty mail order drugs (injection, infused or oral) | $100 copayment (30-day supply) |
- DFW’s plan is a mandatory generic plan. If you choose a brand-name drug when a generic is available, you will pay the difference in cost between the generic and brand-name drug plus the applicable brand copayment.
Plan Notes
- If you enroll in the HDHP, you pay the full negotiated rate for prescription drug costs then the copay after your deductible has been met. Preventive drug costs may be $0 cost to you. See the Prescription Drug Lists on myCigna.com for more information.
- This plan is paired with a Health Savings Account (HSA), so you can set aside pre-tax money for current and future out-of-pocket health care costs.
- DFW Airport contributes $800 (prorated ER contribution) per Individual; $1,600 (prorated ER contribution) per Family toward your account.
- Prescription drug coverage is administered through Cigna and Express Scripts.
- Preventive medications are available at a $0 copayment.
- Maintenance medications can be delivered to your home through Express Scripts Pharmacy (800-835-3784).