Your Medical Benefits
Medical
Group # 00659876
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.
| OAP HDHPQ Plan - HDHPQ OAPIN | Open Access Plus Plan - OAP Mid | Open Access Plus Plan - OAP Buy Up | Open Access Plus Plan - OAP Low | |
|---|---|---|---|---|
| Plan Coinsurance | ||||
| In-Network | Plan pays 80% | Plan pays 80% | Plan pays 80% | Plan pays 80% |
| Out-Of-Network | Not Covered for all benefits | Plan pays 50% | Plan pays 50% | Plan pays 50% |
| Individual Deductible | ||||
| In-Network | Individual - Employee Only: $3,500 | Individual: $3,000 | Individual: $2,000 | Individual: $5,000 |
| Out-Of-Network | Not Covered for all benefits | Individual: $6,000 | Individual: $6,000 | Individual: $10,000 |
| Family Deductible | ||||
| In-Network | Family Maximum: $7,000 | Family: $9,000 | Family: $6,000 | Family: $10,000 |
| Out-Of-Network | Not Covered for all benefits | Family: $18,000 | Family: $18,000 | Family: $20,000 |
| Individual Out-of-Pocket | ||||
| In-Network | Individual - Employee Only: $7,000 Individual - within a Family: $7,000 | Individual: $6,350 | Individual: $5,500 | Individual: $8,200 |
| Out-Of-Network | Not Covered for all benefits | Individual: $15,000 | Individual: $11,000 | Individual: $16,400 |
| Family Out-of-Pocket | ||||
| In-Network | Family Maximum: $14,000 | Family: $12,700 | Family: $11,000 | Family: $16,400 |
| Out-Of-Network | Not Covered for all benefits | Family: $30,000 | Family: $22,000 | Family: $32,800 |
| Primary Care Office Visit | ||||
| In-Network | $30 copay, and plan pays 100% | $40 copay, and plan pays 100% | $35 copay, and plan pays 100% | $30 copay, and plan pays 100% |
| Out-Of-Network | Not Covered for all benefits | Plan pays 50% | Plan pays 50% | Plan pays 50% |
| Specialist Care Office Visit | ||||
| In-Network | $75 copay, and plan pays 100% | $100 copay, and plan pays 100% | $65 copay, and plan pays 100% | $60 copay, and plan pays 100% |
| Out-Of-Network | Not Covered for all benefits | Plan pays 50% | Plan pays 50% | Plan pays 50% |
| Emergency Room | ||||
| $350 copay, and plan pays 100% | $400 copay, and plan pays 100% | $300 copay, and plan pays 100% | $350 copay, and plan pays 100% | |
| Urgent Care | ||||
| In-Network | $100 copay, and plan pays 100% | $100 copay, and plan pays 100% | $70 copay, and plan pays 100% | $100 copay, and plan pays 100% |
| Out-Of-Network | Not Covered for all benefits | Plan pays 50% | Plan pays 50% | Plan pays 50% |
| Outpatient Radiology | ||||
| In-Network | Plan pays 80% | Plan pays 100% | Plan pays 100% | Plan pays 100% |
| Out-Of-Network | Not Covered for all benefits | Plan pays 50% | Plan pays 50% | Plan pays 50% |
| Independent Laboratory | ||||
| In-Network | Plan pays 80% | Plan pays 100% | Plan pays 100% | Plan pays 100% |
| Out-Of-Network | Not Covered for all benefits | Plan pays 50% | Plan pays 50% | Plan pays 50% |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | ||||
| In-Network | $75 copay, and plan pays 100% | $100 copay, and plan pays 100% | $65 copay, and plan pays 100% | $60 copay, and plan pays 100% |
| Out-Of-Network | Not Covered for all benefits | Plan pays 50% | Plan pays 50% | Plan pays 50% |
| Pharmacy Formulary | ||||
| Advantage | Advantage | Advantage | Advantage | |
| Retail Pharmacy Customer Share | ||||
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $80 | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $80 | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $80 | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $60 Non-Preferred Brand: You pay $100 |
| Out-Of-Network | Not Covered for all benefits | Not Covered for all benefits | 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 90-day supply): Generic: You pay $25 Preferred Brand: You pay $125 Non-Preferred Brand: You pay $200 | Retail and Home Delivery (per 90-day supply): Generic: You pay $25 Preferred Brand: You pay $125 Non-Preferred Brand: You pay $200 | Retail and Home Delivery (per 90-day supply): Generic: You pay $25 Preferred Brand: You pay $125 Non-Preferred Brand: You pay $200 | Retail and Home Delivery (per 90-day supply): Generic: You pay $25 Preferred Brand: You pay $150 Non-Preferred Brand: You pay $250 |
| Out-Of-Network | Not Covered for all benefits | Not Covered for all benefits | Home Delivery: Not Covered | Home Delivery: Not Covered |
Plan Coinsurance
| OAP HDHPQ Plan - HDHPQ OAPIN | |
|---|---|
| In-Network | Plan pays 80% |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 50% |
Individual Deductible
| OAP HDHPQ Plan - HDHPQ OAPIN | |
|---|---|
| In-Network | Individual - Employee Only: $3,500 |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Individual: $3,000 |
| Out-of-Network | Individual: $6,000 |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Individual: $2,000 |
| Out-of-Network | Individual: $6,000 |
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Individual: $5,000 |
| Out-of-Network | Individual: $10,000 |
Family Deductible
| OAP HDHPQ Plan - HDHPQ OAPIN | |
|---|---|
| In-Network | Family Maximum: $7,000 |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Family: $9,000 |
| Out-of-Network | Family: $18,000 |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Family: $6,000 |
| Out-of-Network | Family: $18,000 |
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Family: $10,000 |
| Out-of-Network | Family: $20,000 |
Individual Out-of-Pocket
| OAP HDHPQ Plan - HDHPQ OAPIN | |
|---|---|
| In-Network | Individual - Employee Only: $7,000 Individual - within a Family: $7,000 |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Individual: $6,350 |
| Out-of-Network | Individual: $15,000 |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Individual: $5,500 |
| Out-of-Network | Individual: $11,000 |
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Individual: $8,200 |
| Out-of-Network | Individual: $16,400 |
Family Out-of-Pocket
| OAP HDHPQ Plan - HDHPQ OAPIN | |
|---|---|
| In-Network | Family Maximum: $14,000 |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Family: $12,700 |
| Out-of-Network | Family: $30,000 |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Family: $11,000 |
| Out-of-Network | Family: $22,000 |
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Family: $16,400 |
| Out-of-Network | Family: $32,800 |
Primary Care Office Visit
| OAP HDHPQ Plan - HDHPQ OAPIN | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | $40 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | $35 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
Specialist Care Office Visit
| OAP HDHPQ Plan - HDHPQ OAPIN | |
|---|---|
| In-Network | $75 copay, and plan pays 100% |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | $100 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | $65 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | $60 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
Emergency Room
| OAP HDHPQ Plan - HDHPQ OAPIN | |
|---|---|
| $350 copay, and plan pays 100% |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| $400 copay, and plan pays 100% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| $300 copay, and plan pays 100% |
| Open Access Plus Plan - OAP Low | |
|---|---|
| $350 copay, and plan pays 100% |
Urgent Care
| OAP HDHPQ Plan - HDHPQ OAPIN | |
|---|---|
| In-Network | $100 copay, and plan pays 100% |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | $100 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | $70 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | $100 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
Outpatient Radiology
| OAP HDHPQ Plan - HDHPQ OAPIN | |
|---|---|
| In-Network | Plan pays 80% |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 50% |
Independent Laboratory
| OAP HDHPQ Plan - HDHPQ OAPIN | |
|---|---|
| In-Network | Plan pays 80% |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 50% |
Outpatient Physical, Speech, Hearing, and Occupational Therapy
| OAP HDHPQ Plan - HDHPQ OAPIN | |
|---|---|
| In-Network | $75 copay, and plan pays 100% |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | $100 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | $65 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | $60 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
Pharmacy Formulary
| OAP HDHPQ Plan - HDHPQ OAPIN | |
|---|---|
| Advantage |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| Advantage |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| Advantage |
| Open Access Plus Plan - OAP Low | |
|---|---|
| Advantage |
Retail Pharmacy Customer Share
| OAP HDHPQ Plan - HDHPQ OAPIN | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $80 |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $80 |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $80 |
| Out-of-Network | Retail: You pay 50% Your plan pays 50% |
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $60 Non-Preferred Brand: You pay $100 |
| Out-of-Network | Retail: You pay 50% Your plan pays 50% |
Home Delivery Pharmacy Customer Share
| OAP HDHPQ Plan - HDHPQ OAPIN | |
|---|---|
| In-Network | Retail and Home Delivery (per 90-day supply): Generic: You pay $25 Preferred Brand: You pay $125 Non-Preferred Brand: You pay $200 |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Retail and Home Delivery (per 90-day supply): Generic: You pay $25 Preferred Brand: You pay $125 Non-Preferred Brand: You pay $200 |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Retail and Home Delivery (per 90-day supply): Generic: You pay $25 Preferred Brand: You pay $125 Non-Preferred Brand: You pay $200 |
| Out-of-Network | Home Delivery: Not Covered |
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Retail and Home Delivery (per 90-day supply): Generic: You pay $25 Preferred Brand: You pay $150 Non-Preferred Brand: You pay $250 |
| 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 # 00659876
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.
| OAP HDHPQ Plan - HDHPQ OAPIN | Open Access Plus Plan - OAP Mid | Open Access Plus Plan - OAP Buy Up | Open Access Plus Plan - OAP Low | |
|---|---|---|---|---|
| Plan Coinsurance | ||||
| In-Network | Plan pays 80% | Plan pays 80% | Plan pays 80% | Plan pays 80% |
| Out-Of-Network | Not Covered for all benefits | Plan pays 50% | Plan pays 50% | Plan pays 50% |
| Individual Deductible | ||||
| In-Network | Individual - Employee Only: $3,500 | Individual: $3,000 | Individual: $2,000 | Individual: $5,000 |
| Out-Of-Network | Not Covered for all benefits | Individual: $6,000 | Individual: $6,000 | Individual: $10,000 |
| Family Deductible | ||||
| In-Network | Family Maximum: $7,000 | Family: $9,000 | Family: $6,000 | Family: $10,000 |
| Out-Of-Network | Not Covered for all benefits | Family: $18,000 | Family: $18,000 | Family: $20,000 |
| Individual Out-of-Pocket | ||||
| In-Network | Individual - Employee Only: $7,000 Individual - within a Family: $7,000 | Individual: $6,350 | Individual: $5,500 | Individual: $8,200 |
| Out-Of-Network | Not Covered for all benefits | Individual: $15,000 | Individual: $11,000 | Individual: $16,400 |
| Family Out-of-Pocket | ||||
| In-Network | Family Maximum: $14,000 | Family: $12,700 | Family: $11,000 | Family: $16,400 |
| Out-Of-Network | Not Covered for all benefits | Family: $30,000 | Family: $22,000 | Family: $32,800 |
| Primary Care Office Visit | ||||
| In-Network | $30 copay, and plan pays 100% | $40 copay, and plan pays 100% | $35 copay, and plan pays 100% | $30 copay, and plan pays 100% |
| Out-Of-Network | Not Covered for all benefits | Plan pays 50% | Plan pays 50% | Plan pays 50% |
| Specialist Care Office Visit | ||||
| In-Network | $75 copay, and plan pays 100% | $100 copay, and plan pays 100% | $65 copay, and plan pays 100% | $60 copay, and plan pays 100% |
| Out-Of-Network | Not Covered for all benefits | Plan pays 50% | Plan pays 50% | Plan pays 50% |
| Emergency Room | ||||
| $350 copay, and plan pays 100% | $400 copay, and plan pays 100% | $300 copay, and plan pays 100% | $350 copay, and plan pays 100% | |
| Urgent Care | ||||
| In-Network | $100 copay, and plan pays 100% | $100 copay, and plan pays 100% | $70 copay, and plan pays 100% | $100 copay, and plan pays 100% |
| Out-Of-Network | Not Covered for all benefits | Plan pays 50% | Plan pays 50% | Plan pays 50% |
| Outpatient Radiology | ||||
| In-Network | Plan pays 80% | Plan pays 100% | Plan pays 100% | Plan pays 100% |
| Out-Of-Network | Not Covered for all benefits | Plan pays 50% | Plan pays 50% | Plan pays 50% |
| Independent Laboratory | ||||
| In-Network | Plan pays 80% | Plan pays 100% | Plan pays 100% | Plan pays 100% |
| Out-Of-Network | Not Covered for all benefits | Plan pays 50% | Plan pays 50% | Plan pays 50% |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | ||||
| In-Network | $75 copay, and plan pays 100% | $100 copay, and plan pays 100% | $65 copay, and plan pays 100% | $60 copay, and plan pays 100% |
| Out-Of-Network | Not Covered for all benefits | Plan pays 50% | Plan pays 50% | Plan pays 50% |
| Pharmacy Formulary | ||||
| Advantage | Advantage | Advantage | Advantage | |
| Retail Pharmacy Customer Share | ||||
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $80 | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $80 | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $80 | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $60 Non-Preferred Brand: You pay $100 |
| Out-Of-Network | Not Covered for all benefits | Not Covered for all benefits | 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 90-day supply): Generic: You pay $25 Preferred Brand: You pay $125 Non-Preferred Brand: You pay $200 | Retail and Home Delivery (per 90-day supply): Generic: You pay $25 Preferred Brand: You pay $125 Non-Preferred Brand: You pay $200 | Retail and Home Delivery (per 90-day supply): Generic: You pay $25 Preferred Brand: You pay $125 Non-Preferred Brand: You pay $200 | Retail and Home Delivery (per 90-day supply): Generic: You pay $25 Preferred Brand: You pay $150 Non-Preferred Brand: You pay $250 |
| Out-Of-Network | Not Covered for all benefits | Not Covered for all benefits | Home Delivery: Not Covered | Home Delivery: Not Covered |
Plan Coinsurance
| OAP HDHPQ Plan - HDHPQ OAPIN | |
|---|---|
| In-Network | Plan pays 80% |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 50% |
Individual Deductible
| OAP HDHPQ Plan - HDHPQ OAPIN | |
|---|---|
| In-Network | Individual - Employee Only: $3,500 |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Individual: $3,000 |
| Out-of-Network | Individual: $6,000 |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Individual: $2,000 |
| Out-of-Network | Individual: $6,000 |
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Individual: $5,000 |
| Out-of-Network | Individual: $10,000 |
Family Deductible
| OAP HDHPQ Plan - HDHPQ OAPIN | |
|---|---|
| In-Network | Family Maximum: $7,000 |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Family: $9,000 |
| Out-of-Network | Family: $18,000 |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Family: $6,000 |
| Out-of-Network | Family: $18,000 |
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Family: $10,000 |
| Out-of-Network | Family: $20,000 |
Individual Out-of-Pocket
| OAP HDHPQ Plan - HDHPQ OAPIN | |
|---|---|
| In-Network | Individual - Employee Only: $7,000 Individual - within a Family: $7,000 |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Individual: $6,350 |
| Out-of-Network | Individual: $15,000 |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Individual: $5,500 |
| Out-of-Network | Individual: $11,000 |
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Individual: $8,200 |
| Out-of-Network | Individual: $16,400 |
Family Out-of-Pocket
| OAP HDHPQ Plan - HDHPQ OAPIN | |
|---|---|
| In-Network | Family Maximum: $14,000 |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Family: $12,700 |
| Out-of-Network | Family: $30,000 |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Family: $11,000 |
| Out-of-Network | Family: $22,000 |
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Family: $16,400 |
| Out-of-Network | Family: $32,800 |
Primary Care Office Visit
| OAP HDHPQ Plan - HDHPQ OAPIN | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | $40 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | $35 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
Specialist Care Office Visit
| OAP HDHPQ Plan - HDHPQ OAPIN | |
|---|---|
| In-Network | $75 copay, and plan pays 100% |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | $100 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | $65 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | $60 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
Emergency Room
| OAP HDHPQ Plan - HDHPQ OAPIN | |
|---|---|
| $350 copay, and plan pays 100% |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| $400 copay, and plan pays 100% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| $300 copay, and plan pays 100% |
| Open Access Plus Plan - OAP Low | |
|---|---|
| $350 copay, and plan pays 100% |
Urgent Care
| OAP HDHPQ Plan - HDHPQ OAPIN | |
|---|---|
| In-Network | $100 copay, and plan pays 100% |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | $100 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | $70 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | $100 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
Outpatient Radiology
| OAP HDHPQ Plan - HDHPQ OAPIN | |
|---|---|
| In-Network | Plan pays 80% |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 50% |
Independent Laboratory
| OAP HDHPQ Plan - HDHPQ OAPIN | |
|---|---|
| In-Network | Plan pays 80% |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 50% |
Outpatient Physical, Speech, Hearing, and Occupational Therapy
| OAP HDHPQ Plan - HDHPQ OAPIN | |
|---|---|
| In-Network | $75 copay, and plan pays 100% |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | $100 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | $65 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | $60 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
Pharmacy Formulary
| OAP HDHPQ Plan - HDHPQ OAPIN | |
|---|---|
| Advantage |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| Advantage |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| Advantage |
| Open Access Plus Plan - OAP Low | |
|---|---|
| Advantage |
Retail Pharmacy Customer Share
| OAP HDHPQ Plan - HDHPQ OAPIN | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $80 |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $80 |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $80 |
| Out-of-Network | Retail: You pay 50% Your plan pays 50% |
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $60 Non-Preferred Brand: You pay $100 |
| Out-of-Network | Retail: You pay 50% Your plan pays 50% |
Home Delivery Pharmacy Customer Share
| OAP HDHPQ Plan - HDHPQ OAPIN | |
|---|---|
| In-Network | Retail and Home Delivery (per 90-day supply): Generic: You pay $25 Preferred Brand: You pay $125 Non-Preferred Brand: You pay $200 |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Retail and Home Delivery (per 90-day supply): Generic: You pay $25 Preferred Brand: You pay $125 Non-Preferred Brand: You pay $200 |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Retail and Home Delivery (per 90-day supply): Generic: You pay $25 Preferred Brand: You pay $125 Non-Preferred Brand: You pay $200 |
| Out-of-Network | Home Delivery: Not Covered |
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Retail and Home Delivery (per 90-day supply): Generic: You pay $25 Preferred Brand: You pay $150 Non-Preferred Brand: You pay $250 |
| 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.