Retiree
Medical
We are proud to offer you comprehensive medical and prescription drug coverage. The Cigna Mid Plan gives you the freedom to seek care from the provider of your choice. However, you will maximize your benefits and reduce your out-of-pocket costs if you choose a provider who participates in the Cigna network. The calendar-year deductible must be met before certain services are covered.The Cigna Mid Plan also offer many resources and tools to help you maintain a healthy lifestyle. The following provides a brief overview of the plan.
Medical Plan Highlights
| Medical Benefits | HDHP with HSA | Mid Plan | Buy-Up Plan |
|---|---|---|---|
| Deductible UTMB Preferred Network In-Network Non-Network | $2,700 Ind. / $5,400 Fam. $2,700 Ind. / $5,400 Fam. $5,200 Ind. / $10,600 Fam. | $500 Ind. / $1,000 Fam. $1,500 Ind. / $3,000 Fam. $5,000 Ind. / $10,000 Fam. | $250 Ind. / $500 Fam. $750 Ind. / $1,500 Fam. $2,000 Ind. / $4,000 Fam. |
| Out-of-Pocket Maximum UTMB Preferred Network In-Network Non-Network | $5,000 Ind. / $10,000 Fam. $5,000 Ind. / $10,000 Fam. $10,000 Ind. / $20,000 Fam. | N/A $3,500 Ind. / $6,000 Fam. $15,000 Ind. / $30,000 Fam. | $2,000 Ind. / $4,000 Fam. $2,000 Ind. / $4,000 Fam. $10,000 Ind. / $20,000 Fam. |
| Coinsurance UTMB Preferred Network In-Network Non-Network | 10% 20% 40% | 10% 20% 40% | 90% 80% 60% |
| Lifetime Maximum | Unlimited | Unlimited | Unlimited |
| Preventive Care In-Network Non-Network | $0 (no cost sharing) You pay 40% after deductible | $0 (no cost sharing) You pay 40% after deductible | $0 (no cost sharing You pay 40% after deductible |
| Telehealth / Virtual Visit | You pay 20% after deductible (approximately $45) | $5 copay | $5 copay |
| Physician Office Visit | |||
| UTMB & In-Network Age 0-19 UTMB Preferred Network >19 In-Network >19 Non-Network | You pay 10% after deductible You pay 10% after deductible You pay 20% after deductible You pay 40% after deductible | $0 copay $10 copay $25 copay You pay 40% after deductible | $0 copay $10 copay $25 copay You pay 40% after deductible |
| Specialist Office Visit | |||
| UTMB & In-Network Age 0-19 UTMB Preferred Network >19 In-Network >19 Non-Network | You pay 10% after deductible You pay 10% after deductible You pay 20% after deductible You pay 40% after deductible | $0 copay $10 copay $50 copay You pay 40% after deductible | $0 copay $10 copay $40 copay You pay 40% after deductible |
| Basic Lab & Radiology UTMB Preferred Network In-Network Non-Network | N/A You pay 20% after deductible You pay 40% after deductible | You pay 10%* You pay 20%* You 40% after deductible | N/A You pay 20% after deductible You pay 40% after deductible |
| Emergency Room In-Network Non-Network | You pay 20% after deductible You pay 40% after deductible | $150 copay, then ded./coins. $150 copay, then ded./coins. | $150 copay, then ded./coins. $150 copay, then ded./coins. |
| Urgent Care UTMB Preferred Network In-Network Non-Network | N/A You pay 20% after deductible You pay 40% after deductible | $10 copay $50 copay You pay 40% after deductible | N/A $40 copay You pay 40% after deductible |
| Major Lab & Radiology (MRI / CT / PET) UTMB Preferred Network In-Network Non-Network | N/A You pay 20% after deductible You pay 40% after deductible | Prior authorization required You pay 10% after deductible You pay 20% after deductible You pay 40% after deductible | You pay 10% after deductible You pay 20% after deductible You pay 40% after deductible |
| Inpatient Hospital UTMB Preferred Network In-Network Non-Network | You pay 10% after deductible You pay 20% after deductible You pay 40% after deductible | You pay 10% after deductible You pay 20% after deductible You pay 40% after deductible | You pay 10% after deductible You pay 20% after deductible You pay 40% after deductible |
| Outpatient Surgery UTMB Preferred Network In-Network Non-Network | You pay 10% after deductible You pay 20% after deductible You pay 40% after deductible | You pay 10% after deductible You pay 20% after deductible You pay 40% after deductible | You pay 10% after deductible You pay 20% after deductible You pay 40% after deductible |
| Prescriptions Network Retail Pharmacy Network Mail Order / 90-Day Retail Now Preventive Generics CDHP Preventive Drug List Step Therapy / Mandatory Generic | $4/$35/$60/15% $8/$70/$120 $0 copay N/A Step therapy/mandatory generic | $4/$35/$60/15% $8/$70/$120/15% $0 copay N/A Step therapy/mandatory generic | $4/$25/$50/15% $8/$50/$100 $0 copay N/A Step therapy/mandatory generic |
UTMB Preferred Network
UTMB Preferred Network
The University of Texas Medical Branch (UTMB) Health preferred network includes all physicians, hospitals, outpatient facilities, clinics, emergency rooms, urgent care centers and labs. You can make same-day appointments for urgent issues at one of the following UTMB Health locations:
League City
- 266 Gulf Fwy S., Exit 20 (adults only)
- 6465 S. Shore Blvd., Suite 500 (adults and children)
- 2785 Gulf Fwy S., Suite 2.200 (children only)
Dickinson
- 2401 W. FM 646, Suite C (adults and children)
Webster
- 17448 Hwy 3, Suite 200 (adults only)
- 333 N. Texas Ave., Suite 4300 (children only)
You can also call UTMB’s 2-Care Line at 409-CONNECT (409-266-6328) to get 24/7 access to a register nurse, schedule an appointment, order prescription refills and ask for lab results. Be sure to identify yourself as a League City employee or covered dependent.
OneRx
OneRx
Save an average of $750 on your prescriptions with the free OneRx app. You can use the app to:
- View your personal out-of-pocket costs for drugs prescribed at your local pharmacy
- Access special discounts and coupons
- Find out whether step therapy or prior authorization is required before you try to fill a prescription
- Track your medications and stay up to date on the drug list status
For more information and to download the app, go to www.onerx.com.
Cigna Telehealth Connection
Cigna Telehealth Connection
Cigna members have access to two telemedicine options through the Cigna Telehealth Connection Program: Amwell for Cigna and MDLIVE. Telemedicine is a convenient and cost-effective way to get quick medical advice by phone, online or on your mobile device about many non-emergency conditions including:
- Allergies
- Cold and flu symptoms
- Ear infections
- Diarrhea and constipation
- And more!
Whether you are at home, work or on the road, you can get the care you need when and where it’s convenient for you. Even better: doctors can write a prescription, if needed, that you can pick up at an in-network pharmacy.
To get started, log into www.mycigna.com.
Urgent & Convenient Care Centers
Urgent Care Centers
Receive immediate care for non-life-threatening illnesses and injuries at a walk-in urgent care clinic. Urgent care centers often cost less than the emergency room, and offer evening, weekend and 24-hour services. Appointments may be needed. Urgent care centers are located in the following areas:
Tuscan Lakes
2560 State Hwy B
League City, TX
832-982-7228
Nightlight Pediatrics
19325 Gulf Fwy
Webster, TX
832-992-5050
Creekside
4420 W Main St A
League City, TX
832-632-1015
Memorial Hermann Urgent Care
19419 Gulf Fwy #3, Dept 100
Webster, TX
281-316-0885
Memorial Hermann Urgent Care
1505 Winding Way Dr. #112
Friendswood, TX
281-993-3860
Affinity Immediate Care
2600 FM 1764 Rd #190
La Marque, TX
409-359-4375
Convenient Care Centers
Located in some pharmacies, drug stores and grocery stores, these small clinics offer lower cost, basic health care services. Get flu shots and treatment for minor illnesses like strep throat, pink eye, cuts and scrapes. Convenient care clinics are open days, evenings and weekends. You do not need to make an appointment beforehand. Convenient care centers are located in the following areas:
Rediclinic
2955 Gulf Fwy S
League City, TX
877-935-0333
Minuteclinic
2469 Bay Area Blvd
Houston, TX
866-389-2727
Minuteclinic
2900 Broadway St.
Pearland, TX
866-389-2727
Minuteclinic
2800 Bayport Blvd
Seabrook, TX
866-389-2727
MetLife DHMO
MetLife DHMO
With this plan, you choose a primary dental provider to manage your care. There are no charges for most preventive services, no claim forms and no deductibles. Reduced, pre-set charges apply to other services.
MetLife In-Network (Low) PPO Plan
MetLife In-Network (Low) PPO Plan
This plan offers you the freedom and flexibility to use the dentist of your choice. However, you will maximize your benefits and reduce your out-of-pocket costs if you choose a dentist who participates in the MetLife network. If you receive in-network services, you will be responsible for any applicable cost sharing, negotiated charges after benefit maximums are met and costs for non-covered services.
MetLife Out-of-Network (High) PPO Plan
MetLife Out-of-Network (High) PPO Plan
This plan offers you the freedom and flexibility to use the dentist of your choice. However, you will maximize your benefits and reduce your out-of-pocket costs if you choose a dentist who participates in the MetLife network. If you receive out-of-network services, you will be responsible for any applicable cost sharing, charges in excess of the benefit maximum, charges in excess of the negotiated fee schedule amount and charges for non-covered services.
Dental Plan Highlights
| Benefits | DHMO | In-Network Low Plan (PPO) | Out-of-Network High Plan (PPO) |
|---|---|---|---|
| Type I: Preventive Services Reimbursement Level X-rays Cleanings (2 per year) | No waiting period See copay schedule | No waiting period MAC No deductible / 100% | No waiting period 90th percentile No deductible / 100% |
| Type II: Basic Services Fillings Extractions Root canal | See copay schedule | $50 deductible / 90% | $50 deductible / 80% |
| Type III: Major Services Crowns Removable / fixed bridgework Partial or complete dentures | See copay schedule | $50 deductible / 60% | $50 deductible / 50% |
| Type IV: Orthodontia | Adult & Child $2,000 copay | Child Only 50% | Child Only 50% |
| Annual Deductible | |||
| Individual | N/A | $50 | $50 |
| Family | N/A | $150 | $150 |
| Annual Maximum | |||
| Dental Annual Maximum | N/A | $2,000 | $2,000 |
| Orthodontia Lifetime Maximum | N/A | $2,000 | $2,000 |
Vision Plan Highlights
| BENEFITS | |
|---|---|
| Eye Exam Benefit Network Non-Network | $10 copay Up to $40 reimbursement |
| Frames/Lenses | |
| Single Vision Network Non-Network | $25 copay Up to $40 reimbursement |
| Bifocal Lenses Network Non-Network | $25 copay Up to $60 reimbursement |
| Trifocal Lenses Network Non-Network | $25 copay Up to $80 reimbursement |
| Frames/Lenses | $150 allowance or up to $200 at VisionWorks $45 reimbursement |
| Contacts (in lieu of glasses) | |
| Network Medically Necessary Elective | Covered in full $150 allowance |
| Non-Network Medically Necessary Elective | $210 allowance $150 reimbursement |
| Exam Frequency | 12 months |
| Lens Frequency | 12 months |
| Frames Frequency | 12 months |
