Your Medical Benefits
Medical
Group # 00664239
Your employer has chosen Cigna for your healthcare benefits. The information below provides a high-level summary of your out-of-pocket costs (deductibles, copays and/or coinsurance) as well as your benefits and coverage.
| Open Access Plus Plan - OAP Base | Open Access Plus Plan - OAP Buy Up | |
|---|---|---|
| Plan Coinsurance | ||
| In-Network | Plan pays 80% | Plan pays 90% |
| Out-Of-Network | Plan pays 60% | Plan pays 70% |
| Individual Deductible | ||
| In-Network | Individual: $500 | Individual: $500 |
| Out-Of-Network | Individual: $1,000 | Individual: $1,000 |
| Family Deductible | ||
| In-Network | Family: $1,000 | Family: $1,000 |
| Out-Of-Network | Family: $2,000 | Family: $2,000 |
| Individual Out-of-Pocket | ||
| In-Network | Individual: $3,000 | Individual: $2,000 |
| Out-Of-Network | Individual: $7,500 | Individual: $4,000 |
| Family Out-of-Pocket | ||
| In-Network | Family: $6,000 | Family: $4,000 |
| Out-Of-Network | Family: $15,000 | Family: $8,000 |
| Primary Care Office Visit | ||
| In-Network | $25 copay, and plan pays 100% | $20 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 60% | Plan pays 70% |
| Specialist Care Office Visit | ||
| In-Network | $40 copay, and plan pays 100% | $40 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 60% | Plan pays 70% |
| Emergency Room | ||
| $150 copay, and plan pays 80% | $150 copay, and plan pays 90% | |
| Urgent Care | ||
| In-Network | $35 copay, and plan pays 100% | $50 copay, and plan pays 100% |
| Out-Of-Network | $70 copay, and plan pays 100% | Plan pays 70% |
| Outpatient Radiology | ||
| In-Network | Plan pays 80% | Plan pays 90% |
| Out-Of-Network | Plan pays 60% | Plan pays 70% |
| Independent Laboratory | ||
| In-Network | Plan pays 80% | Plan pays 90% |
| Out-Of-Network | Plan pays 60% | Plan pays 70% |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | ||
| In-Network | $25 copay, and plan pays 100% | $20 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 60% | Plan pays 70% |
| Pharmacy Formulary | ||
| Advantage | Advantage | |
| Retail Pharmacy Customer Share | ||
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $20 Non-Preferred Brand: You pay $35 | Retail (per 30-day supply): Generic: You pay $15 Preferred Brand: You pay $35 Non-Preferred Brand: You pay $50 |
| Out-Of-Network | Retail: You pay 50% Your plan pays 50% | Retail: You pay 50% Your plan pays 50% |
| Home Delivery Pharmacy Customer Share | ||
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay 20% up to a maximum of $250 Retail and Home Delivery (per 90-day supply): Generic: You pay $20 Preferred Brand: You pay $40 Non-Preferred Brand: You pay $70 | Retail and Home Delivery (per 30-day supply): Specialty: You pay 20% up to a maximum of $250 Retail and Home Delivery (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $70 Non-Preferred Brand: You pay $100 |
| Out-Of-Network | Home Delivery: Not Covered | Home Delivery: Not Covered |
Plan Coinsurance
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 70% |
Individual Deductible
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Individual: $500 |
| Out-of-Network | Individual: $1,000 |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Individual: $500 |
| Out-of-Network | Individual: $1,000 |
Family Deductible
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Family: $1,000 |
| Out-of-Network | Family: $2,000 |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Family: $1,000 |
| Out-of-Network | Family: $2,000 |
Individual Out-of-Pocket
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Individual: $3,000 |
| Out-of-Network | Individual: $7,500 |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Individual: $2,000 |
| Out-of-Network | Individual: $4,000 |
Family Out-of-Pocket
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Family: $6,000 |
| Out-of-Network | Family: $15,000 |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Family: $4,000 |
| Out-of-Network | Family: $8,000 |
Primary Care Office Visit
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | $25 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | $20 copay, and plan pays 100% |
| Out-of-Network | Plan pays 70% |
Specialist Care Office Visit
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | $40 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | $40 copay, and plan pays 100% |
| Out-of-Network | Plan pays 70% |
Emergency Room
| Open Access Plus Plan - OAP Base | |
|---|---|
| $150 copay, and plan pays 80% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| $150 copay, and plan pays 90% |
Urgent Care
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | $35 copay, and plan pays 100% |
| Out-of-Network | $70 copay, and plan pays 100% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | $50 copay, and plan pays 100% |
| Out-of-Network | Plan pays 70% |
Outpatient Radiology
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 70% |
Independent Laboratory
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 70% |
Outpatient Physical, Speech, Hearing, and Occupational Therapy
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | $25 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | $20 copay, and plan pays 100% |
| Out-of-Network | Plan pays 70% |
Pharmacy Formulary
| Open Access Plus Plan - OAP Base | |
|---|---|
| Advantage |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| Advantage |
Retail Pharmacy Customer Share
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $20 Non-Preferred Brand: You pay $35 |
| Out-of-Network | Retail: You pay 50% Your plan pays 50% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $15 Preferred Brand: You pay $35 Non-Preferred Brand: You pay $50 |
| Out-of-Network | Retail: You pay 50% Your plan pays 50% |
Home Delivery Pharmacy Customer Share
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay 20% up to a maximum of $250 Retail and Home Delivery (per 90-day supply): Generic: You pay $20 Preferred Brand: You pay $40 Non-Preferred Brand: You pay $70 |
| Out-of-Network | Home Delivery: Not Covered |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay 20% up to a maximum of $250 Retail and Home Delivery (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $70 Non-Preferred Brand: You pay $100 |
| Out-of-Network | Home Delivery: Not Covered |
All plans have exclusions and limitations. For a summary of these exclusions and limitations, view the Summary of Benefits and Coverage.
Medical
Group # 00664239
Your employer has chosen Cigna for your healthcare benefits. The information below provides a high-level summary of your out-of-pocket costs (deductibles, copays and/or coinsurance) as well as your benefits and coverage.
| Open Access Plus Plan - OAP Base | Open Access Plus Plan - OAP Buy Up | |
|---|---|---|
| Plan Coinsurance | ||
| In-Network | Plan pays 80% | Plan pays 90% |
| Out-Of-Network | Plan pays 60% | Plan pays 70% |
| Individual Deductible | ||
| In-Network | Individual: $500 | Individual: $500 |
| Out-Of-Network | Individual: $1,000 | Individual: $1,000 |
| Family Deductible | ||
| In-Network | Family: $1,000 | Family: $1,000 |
| Out-Of-Network | Family: $2,000 | Family: $2,000 |
| Individual Out-of-Pocket | ||
| In-Network | Individual: $3,000 | Individual: $2,000 |
| Out-Of-Network | Individual: $7,500 | Individual: $4,000 |
| Family Out-of-Pocket | ||
| In-Network | Family: $6,000 | Family: $4,000 |
| Out-Of-Network | Family: $15,000 | Family: $8,000 |
| Primary Care Office Visit | ||
| In-Network | $25 copay, and plan pays 100% | $20 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 60% | Plan pays 70% |
| Specialist Care Office Visit | ||
| In-Network | $40 copay, and plan pays 100% | $40 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 60% | Plan pays 70% |
| Emergency Room | ||
| $150 copay, and plan pays 80% | $150 copay, and plan pays 90% | |
| Urgent Care | ||
| In-Network | $35 copay, and plan pays 100% | $50 copay, and plan pays 100% |
| Out-Of-Network | $70 copay, and plan pays 100% | Plan pays 70% |
| Outpatient Radiology | ||
| In-Network | Plan pays 80% | Plan pays 90% |
| Out-Of-Network | Plan pays 60% | Plan pays 70% |
| Independent Laboratory | ||
| In-Network | Plan pays 80% | Plan pays 90% |
| Out-Of-Network | Plan pays 60% | Plan pays 70% |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | ||
| In-Network | $25 copay, and plan pays 100% | $20 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 60% | Plan pays 70% |
| Pharmacy Formulary | ||
| Advantage | Advantage | |
| Retail Pharmacy Customer Share | ||
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $20 Non-Preferred Brand: You pay $35 | Retail (per 30-day supply): Generic: You pay $15 Preferred Brand: You pay $35 Non-Preferred Brand: You pay $50 |
| Out-Of-Network | Retail: You pay 50% Your plan pays 50% | Retail: You pay 50% Your plan pays 50% |
| Home Delivery Pharmacy Customer Share | ||
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay 20% up to a maximum of $250 Retail and Home Delivery (per 90-day supply): Generic: You pay $20 Preferred Brand: You pay $40 Non-Preferred Brand: You pay $70 | Retail and Home Delivery (per 30-day supply): Specialty: You pay 20% up to a maximum of $250 Retail and Home Delivery (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $70 Non-Preferred Brand: You pay $100 |
| Out-Of-Network | Home Delivery: Not Covered | Home Delivery: Not Covered |
Plan Coinsurance
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 70% |
Individual Deductible
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Individual: $500 |
| Out-of-Network | Individual: $1,000 |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Individual: $500 |
| Out-of-Network | Individual: $1,000 |
Family Deductible
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Family: $1,000 |
| Out-of-Network | Family: $2,000 |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Family: $1,000 |
| Out-of-Network | Family: $2,000 |
Individual Out-of-Pocket
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Individual: $3,000 |
| Out-of-Network | Individual: $7,500 |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Individual: $2,000 |
| Out-of-Network | Individual: $4,000 |
Family Out-of-Pocket
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Family: $6,000 |
| Out-of-Network | Family: $15,000 |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Family: $4,000 |
| Out-of-Network | Family: $8,000 |
Primary Care Office Visit
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | $25 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | $20 copay, and plan pays 100% |
| Out-of-Network | Plan pays 70% |
Specialist Care Office Visit
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | $40 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | $40 copay, and plan pays 100% |
| Out-of-Network | Plan pays 70% |
Emergency Room
| Open Access Plus Plan - OAP Base | |
|---|---|
| $150 copay, and plan pays 80% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| $150 copay, and plan pays 90% |
Urgent Care
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | $35 copay, and plan pays 100% |
| Out-of-Network | $70 copay, and plan pays 100% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | $50 copay, and plan pays 100% |
| Out-of-Network | Plan pays 70% |
Outpatient Radiology
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 70% |
Independent Laboratory
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 70% |
Outpatient Physical, Speech, Hearing, and Occupational Therapy
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | $25 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | $20 copay, and plan pays 100% |
| Out-of-Network | Plan pays 70% |
Pharmacy Formulary
| Open Access Plus Plan - OAP Base | |
|---|---|
| Advantage |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| Advantage |
Retail Pharmacy Customer Share
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $20 Non-Preferred Brand: You pay $35 |
| Out-of-Network | Retail: You pay 50% Your plan pays 50% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $15 Preferred Brand: You pay $35 Non-Preferred Brand: You pay $50 |
| Out-of-Network | Retail: You pay 50% Your plan pays 50% |
Home Delivery Pharmacy Customer Share
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay 20% up to a maximum of $250 Retail and Home Delivery (per 90-day supply): Generic: You pay $20 Preferred Brand: You pay $40 Non-Preferred Brand: You pay $70 |
| Out-of-Network | Home Delivery: Not Covered |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay 20% up to a maximum of $250 Retail and Home Delivery (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $70 Non-Preferred Brand: You pay $100 |
| Out-of-Network | Home Delivery: Not Covered |
All plans have exclusions and limitations. For a summary of these exclusions and limitations, view the Summary of Benefits and Coverage.