2026 CIGNA Silver PFA Summary of Benefits

CIGNA Plan Deductible: Individual: $4,000 Family: $8,000 Plan Debit Card Deductible Responsibility: Debit Card Allotment: Individual: $1,500 Family: $3,000 Member Deductible Responsibility: Member pays the remaining Individual: $2,500 Family: $5,000 Office & Specialist Visit: Deductible then; 30% coinsurance Member Responsibility: Deductible then; 30% coinsurance Emergency Room (waived if admitted): Deductible then; 30% coinsurance Member Responsibility: Deductible then; 30% coinsurance Inpatient Hospitalization: Deductible then; 30% coinsurance Member Responsibility: Deductible then; 30% coinsurance Day Surgery: Deductible then; 30% coinsurance Member Responsibility: Deductible then; 30% coinsurance High Tech Imaging (MRI, CT Scans, PET): Deductible then; 30% coinsurance Member Responsibility: Deductible then; 30% coinsurance Diagnostic Tests, Labs & X-Rays: Deductible then; 30% coinsurance Member Responsibility: Deductible then; 30% coinsurance Once employee reaches $6,500 individual and $13,000 for Family of out of pocket max expenses employees can manually submit remaining expenses for reimbursement. Deductible applies then; Prescription Drugs: Retail - 30 Day Supply Tier 1: 30% coinsurance Tier 2: 30% coinsurance Tier 3: 30% coinsurance Prescription Drugs: Mail Order - 90 Day Supply Tier 1: 30% coinsurance Tier 2: 30% coinsurance Tier 3: 30% coinsurance Your employer AESOP Auto Parts has arranged for Reimbursement Specialists, Inc. (RSI) to administer the deductible portions of your CIGNA health plan. You will be provided a RSI debit card preloaded with an allotment of funds to be used on eligible deductible expenses associated with your plan. The benefits shown here are a snapshot of the benefits provided by your employer. For a detailed explanation of your benefits see the CIGNA benefit summaries. January 1, 2026– December 31, 2026 Silver PFA PLAN