Your Medical Benefits
Medical
Group # 00637515
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 In-Network - OAPIN | Open Access Plus - OAP | Open Access Plus - HDHPQ OAP | |
|---|---|---|---|
| Plan Coinsurance | |||
| In-Network | Plan pays 100% | Plan pays 80% | Plan pays 80% |
| Out-Of-Network | Not Covered for all benefits | Plan pays 60% | Plan pays 60% |
| Individual Deductible | |||
| In-Network | Individual: None | Individual: $500 | Individual - Employee Only: $1,700 Individual - within a Family: $3,400 |
| Out-Of-Network | Not Covered for all benefits | Individual: $1,500 | Individual - Employee Only: $3,400 Individual - within a Family: $6,600 |
| Family Deductible | |||
| In-Network | Family: None | Family: $1,500 | Family Maximum: $3,400 |
| Out-Of-Network | Not Covered for all benefits | Family: $4,500 | Family Maximum: $6,800 |
| Individual Out-of-Pocket | |||
| In-Network | Individual: $2,500 | Individual: $3,500 | Individual - Employee Only: $3,000 Individual - within a Family: $3,400 |
| Out-Of-Network | Not Covered for all benefits | Individual: $10,500 | Individual - Employee Only: $9,000 Individual - within a Family: $9,000 |
| Family Out-of-Pocket | |||
| In-Network | Family: $5,000 | Family: $7,000 | Family Maximum: $6,000 |
| Out-Of-Network | Not Covered for all benefits | Family: $21,000 | Family Maximum: $18,000 |
| Primary Care Office Visit | |||
| In-Network | $30 copay, and plan pays 100% | $20 copay, and plan pays 100% | Plan pays 80% |
| Out-Of-Network | Not Covered for all benefits | Plan pays 60% | Plan pays 60% |
| Specialist Care Office Visit | |||
| In-Network | $30 copay, and plan pays 100% | $40 copay, and plan pays 100% | Plan pays 80% |
| Out-Of-Network | Not Covered for all benefits | Plan pays 60% | Plan pays 60% |
| Emergency Room | |||
| $100 copay, and plan pays 100% | $150 copay, and plan pays 80% | Plan pays 80% | |
| Urgent Care | |||
| In-Network | $25 copay, and plan pays 100% | $25 copay, and plan pays 100% | Plan pays 80% |
| Out-Of-Network | Not Covered for all benefits | Plan pays 60% | Plan pays 60% |
| Outpatient Radiology | |||
| In-Network | Plan pays 100% | Plan pays 80% | Plan pays 80% |
| Out-Of-Network | Not Covered for all benefits | Plan pays 60% | Plan pays 60% |
| Independent Laboratory | |||
| In-Network | Plan pays 100% | Plan pays 80% | Plan pays 80% |
| Out-Of-Network | Not Covered for all benefits | Plan pays 60% | Plan pays 60% |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | |||
| In-Network | $30 copay, and plan pays 100% | $20 copay, and plan pays 100% | Plan pays 80% |
| Out-Of-Network | Not Covered for all benefits | Plan pays 60% | Plan pays 60% |
| Pharmacy Formulary | |||
| Performance | Performance | Performance | |
| Retail Pharmacy Customer Share | |||
| In-Network | Retail (per 30-day supply): Generic: You pay $15 Preferred Brand: You pay $35 Non-Preferred Brand: You pay $50 | Retail (per 30-day supply): Generic: You pay $15 Preferred Brand: You pay $30 Non-Preferred Brand: You pay $50 | Retail (per 30-day supply): Generic: You pay $15 Preferred Brand: You pay $40 Non-Preferred Brand: You pay $60 |
| Out-Of-Network | Retail: You pay 50% Your plan pays 50% | Retail: You pay 50% Your plan pays 50% | Retail: You pay 40% Your plan pays 60% |
| Home Delivery Pharmacy Customer Share | |||
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay 30% up to a maximum of $250 Retail and Home Delivery (per 90-day supply): Generic: You pay $38 Preferred Brand: You pay $105 Non-Preferred Brand: You pay $150 | Retail and Home Delivery (per 30-day supply): Specialty: You pay 30% up to a maximum of $250 Retail and Home Delivery (per 90-day supply): Generic: You pay $38 Preferred Brand: You pay $90 Non-Preferred Brand: You pay $150 | Retail and Home Delivery (per 30-day supply): Specialty: You pay 30% up to a maximum of $250 Retail and Home Delivery (per 90-day supply): Generic: You pay $38 Preferred Brand: You pay $120 Non-Preferred Brand: You pay $180 |
| Out-Of-Network | Home Delivery: Not Covered | Home Delivery: Not Covered | Home Delivery: Not Covered |
Plan Coinsurance
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | Plan pays 100% |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
Individual Deductible
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | Individual: None |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Individual: $500 |
| Out-of-Network | Individual: $1,500 |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Individual - Employee Only: $1,700 Individual - within a Family: $3,400 |
| Out-of-Network | Individual - Employee Only: $3,400 Individual - within a Family: $6,600 |
Family Deductible
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | Family: None |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Family: $1,500 |
| Out-of-Network | Family: $4,500 |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Family Maximum: $3,400 |
| Out-of-Network | Family Maximum: $6,800 |
Individual Out-of-Pocket
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | Individual: $2,500 |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Individual: $3,500 |
| Out-of-Network | Individual: $10,500 |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Individual - Employee Only: $3,000 Individual - within a Family: $3,400 |
| Out-of-Network | Individual - Employee Only: $9,000 Individual - within a Family: $9,000 |
Family Out-of-Pocket
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | Family: $5,000 |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Family: $7,000 |
| Out-of-Network | Family: $21,000 |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Family Maximum: $6,000 |
| Out-of-Network | Family Maximum: $18,000 |
Primary Care Office Visit
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| Open Access Plus - OAP | |
|---|---|
| In-Network | $20 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
Specialist Care Office Visit
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| Open Access Plus - OAP | |
|---|---|
| In-Network | $40 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
Emergency Room
| Open Access Plus In-Network - OAPIN | |
|---|---|
| $100 copay, and plan pays 100% |
| Open Access Plus - OAP | |
|---|---|
| $150 copay, and plan pays 80% |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| Plan pays 80% |
Urgent Care
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | $25 copay, and plan pays 100% |
| Open Access Plus - OAP | |
|---|---|
| In-Network | $25 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
Outpatient Radiology
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | Plan pays 100% |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
Independent Laboratory
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | Plan pays 100% |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
Outpatient Physical, Speech, Hearing, and Occupational Therapy
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| Open Access Plus - OAP | |
|---|---|
| In-Network | $20 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
Pharmacy Formulary
| Open Access Plus In-Network - OAPIN | |
|---|---|
| Performance |
| Open Access Plus - OAP | |
|---|---|
| Performance |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| Performance |
Retail Pharmacy Customer Share
| Open Access Plus In-Network - OAPIN | |
|---|---|
| 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% |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $15 Preferred Brand: You pay $30 Non-Preferred Brand: You pay $50 |
| Out-of-Network | Retail: You pay 50% Your plan pays 50% |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $15 Preferred Brand: You pay $40 Non-Preferred Brand: You pay $60 |
| Out-of-Network | Retail: You pay 40% Your plan pays 60% |
Home Delivery Pharmacy Customer Share
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay 30% up to a maximum of $250 Retail and Home Delivery (per 90-day supply): Generic: You pay $38 Preferred Brand: You pay $105 Non-Preferred Brand: You pay $150 |
| Out-of-Network | Home Delivery: Not Covered |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay 30% up to a maximum of $250 Retail and Home Delivery (per 90-day supply): Generic: You pay $38 Preferred Brand: You pay $90 Non-Preferred Brand: You pay $150 |
| Out-of-Network | Home Delivery: Not Covered |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay 30% up to a maximum of $250 Retail and Home Delivery (per 90-day supply): Generic: You pay $38 Preferred Brand: You pay $120 Non-Preferred Brand: You pay $180 |
| 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 # 00637515
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 In-Network - OAPIN | Open Access Plus - OAP | Open Access Plus - HDHPQ OAP | |
|---|---|---|---|
| Plan Coinsurance | |||
| In-Network | Plan pays 100% | Plan pays 80% | Plan pays 80% |
| Out-Of-Network | Not Covered for all benefits | Plan pays 60% | Plan pays 60% |
| Individual Deductible | |||
| In-Network | Individual: None | Individual: $500 | Individual - Employee Only: $1,700 Individual - within a Family: $3,400 |
| Out-Of-Network | Not Covered for all benefits | Individual: $1,500 | Individual - Employee Only: $3,400 Individual - within a Family: $6,600 |
| Family Deductible | |||
| In-Network | Family: None | Family: $1,500 | Family Maximum: $3,400 |
| Out-Of-Network | Not Covered for all benefits | Family: $4,500 | Family Maximum: $6,800 |
| Individual Out-of-Pocket | |||
| In-Network | Individual: $2,500 | Individual: $3,500 | Individual - Employee Only: $3,000 Individual - within a Family: $3,400 |
| Out-Of-Network | Not Covered for all benefits | Individual: $10,500 | Individual - Employee Only: $9,000 Individual - within a Family: $9,000 |
| Family Out-of-Pocket | |||
| In-Network | Family: $5,000 | Family: $7,000 | Family Maximum: $6,000 |
| Out-Of-Network | Not Covered for all benefits | Family: $21,000 | Family Maximum: $18,000 |
| Primary Care Office Visit | |||
| In-Network | $30 copay, and plan pays 100% | $20 copay, and plan pays 100% | Plan pays 80% |
| Out-Of-Network | Not Covered for all benefits | Plan pays 60% | Plan pays 60% |
| Specialist Care Office Visit | |||
| In-Network | $30 copay, and plan pays 100% | $40 copay, and plan pays 100% | Plan pays 80% |
| Out-Of-Network | Not Covered for all benefits | Plan pays 60% | Plan pays 60% |
| Emergency Room | |||
| $100 copay, and plan pays 100% | $150 copay, and plan pays 80% | Plan pays 80% | |
| Urgent Care | |||
| In-Network | $25 copay, and plan pays 100% | $25 copay, and plan pays 100% | Plan pays 80% |
| Out-Of-Network | Not Covered for all benefits | Plan pays 60% | Plan pays 60% |
| Outpatient Radiology | |||
| In-Network | Plan pays 100% | Plan pays 80% | Plan pays 80% |
| Out-Of-Network | Not Covered for all benefits | Plan pays 60% | Plan pays 60% |
| Independent Laboratory | |||
| In-Network | Plan pays 100% | Plan pays 80% | Plan pays 80% |
| Out-Of-Network | Not Covered for all benefits | Plan pays 60% | Plan pays 60% |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | |||
| In-Network | $30 copay, and plan pays 100% | $20 copay, and plan pays 100% | Plan pays 80% |
| Out-Of-Network | Not Covered for all benefits | Plan pays 60% | Plan pays 60% |
| Pharmacy Formulary | |||
| Performance | Performance | Performance | |
| Retail Pharmacy Customer Share | |||
| In-Network | Retail (per 30-day supply): Generic: You pay $15 Preferred Brand: You pay $35 Non-Preferred Brand: You pay $50 | Retail (per 30-day supply): Generic: You pay $15 Preferred Brand: You pay $30 Non-Preferred Brand: You pay $50 | Retail (per 30-day supply): Generic: You pay $15 Preferred Brand: You pay $40 Non-Preferred Brand: You pay $60 |
| Out-Of-Network | Retail: You pay 50% Your plan pays 50% | Retail: You pay 50% Your plan pays 50% | Retail: You pay 40% Your plan pays 60% |
| Home Delivery Pharmacy Customer Share | |||
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay 30% up to a maximum of $250 Retail and Home Delivery (per 90-day supply): Generic: You pay $38 Preferred Brand: You pay $105 Non-Preferred Brand: You pay $150 | Retail and Home Delivery (per 30-day supply): Specialty: You pay 30% up to a maximum of $250 Retail and Home Delivery (per 90-day supply): Generic: You pay $38 Preferred Brand: You pay $90 Non-Preferred Brand: You pay $150 | Retail and Home Delivery (per 30-day supply): Specialty: You pay 30% up to a maximum of $250 Retail and Home Delivery (per 90-day supply): Generic: You pay $38 Preferred Brand: You pay $120 Non-Preferred Brand: You pay $180 |
| Out-Of-Network | Home Delivery: Not Covered | Home Delivery: Not Covered | Home Delivery: Not Covered |
Plan Coinsurance
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | Plan pays 100% |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
Individual Deductible
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | Individual: None |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Individual: $500 |
| Out-of-Network | Individual: $1,500 |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Individual - Employee Only: $1,700 Individual - within a Family: $3,400 |
| Out-of-Network | Individual - Employee Only: $3,400 Individual - within a Family: $6,600 |
Family Deductible
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | Family: None |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Family: $1,500 |
| Out-of-Network | Family: $4,500 |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Family Maximum: $3,400 |
| Out-of-Network | Family Maximum: $6,800 |
Individual Out-of-Pocket
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | Individual: $2,500 |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Individual: $3,500 |
| Out-of-Network | Individual: $10,500 |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Individual - Employee Only: $3,000 Individual - within a Family: $3,400 |
| Out-of-Network | Individual - Employee Only: $9,000 Individual - within a Family: $9,000 |
Family Out-of-Pocket
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | Family: $5,000 |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Family: $7,000 |
| Out-of-Network | Family: $21,000 |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Family Maximum: $6,000 |
| Out-of-Network | Family Maximum: $18,000 |
Primary Care Office Visit
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| Open Access Plus - OAP | |
|---|---|
| In-Network | $20 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
Specialist Care Office Visit
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| Open Access Plus - OAP | |
|---|---|
| In-Network | $40 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
Emergency Room
| Open Access Plus In-Network - OAPIN | |
|---|---|
| $100 copay, and plan pays 100% |
| Open Access Plus - OAP | |
|---|---|
| $150 copay, and plan pays 80% |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| Plan pays 80% |
Urgent Care
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | $25 copay, and plan pays 100% |
| Open Access Plus - OAP | |
|---|---|
| In-Network | $25 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
Outpatient Radiology
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | Plan pays 100% |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
Independent Laboratory
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | Plan pays 100% |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
Outpatient Physical, Speech, Hearing, and Occupational Therapy
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| Open Access Plus - OAP | |
|---|---|
| In-Network | $20 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
Pharmacy Formulary
| Open Access Plus In-Network - OAPIN | |
|---|---|
| Performance |
| Open Access Plus - OAP | |
|---|---|
| Performance |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| Performance |
Retail Pharmacy Customer Share
| Open Access Plus In-Network - OAPIN | |
|---|---|
| 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% |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $15 Preferred Brand: You pay $30 Non-Preferred Brand: You pay $50 |
| Out-of-Network | Retail: You pay 50% Your plan pays 50% |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $15 Preferred Brand: You pay $40 Non-Preferred Brand: You pay $60 |
| Out-of-Network | Retail: You pay 40% Your plan pays 60% |
Home Delivery Pharmacy Customer Share
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay 30% up to a maximum of $250 Retail and Home Delivery (per 90-day supply): Generic: You pay $38 Preferred Brand: You pay $105 Non-Preferred Brand: You pay $150 |
| Out-of-Network | Home Delivery: Not Covered |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay 30% up to a maximum of $250 Retail and Home Delivery (per 90-day supply): Generic: You pay $38 Preferred Brand: You pay $90 Non-Preferred Brand: You pay $150 |
| Out-of-Network | Home Delivery: Not Covered |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay 30% up to a maximum of $250 Retail and Home Delivery (per 90-day supply): Generic: You pay $38 Preferred Brand: You pay $120 Non-Preferred Brand: You pay $180 |
| 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.