Your Medical Benefits
OAP HDHPQ Plan - HDHPQ OAPIN
Benefit Summary
Group # 00659876
Open Access Plus (OAP) gives you access to thousands of providers, doctors, hospitals and specialists– plus programs and services to support your whole-health needs.
A HDHP, or High Deductible Health Plan, can be combined with a tax-advantaged saving account allowing you to pay for certain medical expenses with money free from federal taxes. Until you reach your deductible, you must pay for most of your health care expenses out-of-pocket.
Note: The Plan deductible always applies before any benefit copay/deductible or coinsurance.
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Plan Documents
| In-Network | Out-of-Network | |
|---|---|---|
| Plan Name | OAP HDHPQ Plan - HDHPQ OAPIN | |
| Plan Coinsurance | Plan pays 80% | Not Covered for all benefits |
| Individual Deductible | Individual - Employee Only: $3,500 | Not Covered for all benefits |
| Family Deductible | Family Maximum: $7,000 | Not Covered for all benefits |
| Individual Out-of-Pocket | Individual - Employee Only: $7,000 Individual - within a Family: $7,000 | Not Covered for all benefits |
| Family Out-of-Pocket | Family Maximum: $14,000 | Not Covered for all benefits |
| Primary Care Office Visit | $30 copay, and plan pays 100% | Not Covered for all benefits |
| Specialist Care Office Visit | $75 copay, and plan pays 100% | Not Covered for all benefits |
| Emergency Room | $350 copay, and plan pays 100% | |
| Urgent Care | $100 copay, and plan pays 100% | Not Covered for all benefits |
| Outpatient Radiology | Plan pays 80% | Not Covered for all benefits |
| Independent Laboratory | Plan pays 80% | Not Covered for all benefits |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | $75 copay, and plan pays 100% | Not Covered for all benefits |
| Pharmacy Formulary | Advantage | |
| Retail Pharmacy Customer Share | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $80 | Not Covered for all benefits |
| Home Delivery Pharmacy Customer Share | Retail and Home Delivery (per 90-day supply): Generic: You pay $25 Preferred Brand: You pay $125 Non-Preferred Brand: You pay $200 | Not Covered for all benefits |
All plans have exclusions and limitations. For a summary of these exclusions and limitations, view the Summary of Benefits and Coverage.
Benefit Summary
Group # 00659876
Open Access Plus (OAP) gives you access to thousands of providers, doctors, hospitals and specialists– plus programs and services to support your whole-health needs.
A HDHP, or High Deductible Health Plan, can be combined with a tax-advantaged saving account allowing you to pay for certain medical expenses with money free from federal taxes. Until you reach your deductible, you must pay for most of your health care expenses out-of-pocket.
Note: The Plan deductible always applies before any benefit copay/deductible or coinsurance.
| In-Network | Out-of-Network | |
|---|---|---|
| Plan Name | OAP HDHPQ Plan - HDHPQ OAPIN | |
| Plan Coinsurance | Plan pays 80% | Not Covered for all benefits |
| Individual Deductible | Individual - Employee Only: $3,500 | Not Covered for all benefits |
| Family Deductible | Family Maximum: $7,000 | Not Covered for all benefits |
| Individual Out-of-Pocket | Individual - Employee Only: $7,000 Individual - within a Family: $7,000 | Not Covered for all benefits |
| Family Out-of-Pocket | Family Maximum: $14,000 | Not Covered for all benefits |
| Primary Care Office Visit | $30 copay, and plan pays 100% | Not Covered for all benefits |
| Specialist Care Office Visit | $75 copay, and plan pays 100% | Not Covered for all benefits |
| Emergency Room | $350 copay, and plan pays 100% | |
| Urgent Care | $100 copay, and plan pays 100% | Not Covered for all benefits |
| Outpatient Radiology | Plan pays 80% | Not Covered for all benefits |
| Independent Laboratory | Plan pays 80% | Not Covered for all benefits |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | $75 copay, and plan pays 100% | Not Covered for all benefits |
| Pharmacy Formulary | Advantage | |
| Retail Pharmacy Customer Share | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $80 | Not Covered for all benefits |
| Home Delivery Pharmacy Customer Share | Retail and Home Delivery (per 90-day supply): Generic: You pay $25 Preferred Brand: You pay $125 Non-Preferred Brand: You pay $200 | Not Covered for all benefits |
All plans have exclusions and limitations. For a summary of these exclusions and limitations, view the Summary of Benefits and Coverage.