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2016 — 2017 Plan Design , <br />J <br />F -6 Page 76 <br />2016 - 2017 Renewal <br />Renewal <br />CIGNA <br />Self- funded OAP <br />CIGNA <br />Self- funded HSA <br />In- Network <br />In- Network <br />Health Reimbursement <br />Account <br />Health Savings Account <br />County Contribution <br />$225 <br />$750 <br />Coinsurance Limit <br />Single $4,150 <br />Family $9,300 <br />(includes deductible) <br />Single $3,500 <br />Family $5,000 <br />(Includes deductible) <br />Lifetime Maximum <br />None <br />None <br />Deductible - Individual <br />$1,000 <br />$1,500 <br />Deductible - Family <br />$3,000 <br />$3,000 <br />Office Visits to Your PCP <br />$30 Copay <br />Ded /Coinsurance <br />Office Visit to a Specialist <br />Ded /Coinsurance <br />Ded /Coinsurance <br />Wellness Benefits <br />100% <br />100% <br />Inpatient Hospital Care <br />Ded /Coinsurance <br />Ded /Coinsurance <br />Outpatient Surgery <br />Ded /Coinsurance <br />Ded /Coinsurance <br />Emergency Room Visit <br />Ded /Coinsurance <br />Ded /Coinsurance <br />Urgent Care <br />Ded /Coinsurance <br />Ded /Coinsurance <br />Prescription Drugs <br />$5/$45/$60 - 2x Mail <br />Ded /Coinsurance <br />Benefit Percentage <br />80% <br />80% <br />J <br />F -6 Page 76 <br />