Your Medical Benefits
Open Access Plus - OAP
Benefit Summary
Group # 00637515
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.
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Plan Documents
| In-Network | Out-of-Network | |
|---|---|---|
| Plan Name | Open Access Plus - OAP | |
| Plan Coinsurance | Plan pays 80% | Plan pays 60% |
| Individual Deductible | Individual: $500 | Individual: $1,500 |
| Family Deductible | Family: $1,500 | Family: $4,500 |
| Individual Out-of-Pocket | Individual: $3,500 | Individual: $10,500 |
| Family Out-of-Pocket | Family: $7,000 | Family: $21,000 |
| Primary Care Office Visit | $20 copay, and plan pays 100% | Plan pays 60% |
| Specialist Care Office Visit | $40 copay, and plan pays 100% | Plan pays 60% |
| Emergency Room | $150 copay, and plan pays 80% | |
| Urgent Care | $25 copay, and plan pays 100% | Plan pays 60% |
| Outpatient Radiology | Plan pays 80% | Plan pays 60% |
| Independent Laboratory | Plan pays 80% | Plan pays 60% |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | $20 copay, and plan pays 100% | Plan pays 60% |
| Pharmacy Formulary | Performance | |
| Retail Pharmacy Customer Share | Retail (per 30-day supply): Generic: You pay $15 Preferred Brand: You pay $30 Non-Preferred Brand: You pay $50 | Retail: You pay 50% Your plan pays 50% |
| Home Delivery Pharmacy Customer Share | 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 | 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.
Benefit Summary
Group # 00637515
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.
| In-Network | Out-of-Network | |
|---|---|---|
| Plan Name | Open Access Plus - OAP | |
| Plan Coinsurance | Plan pays 80% | Plan pays 60% |
| Individual Deductible | Individual: $500 | Individual: $1,500 |
| Family Deductible | Family: $1,500 | Family: $4,500 |
| Individual Out-of-Pocket | Individual: $3,500 | Individual: $10,500 |
| Family Out-of-Pocket | Family: $7,000 | Family: $21,000 |
| Primary Care Office Visit | $20 copay, and plan pays 100% | Plan pays 60% |
| Specialist Care Office Visit | $40 copay, and plan pays 100% | Plan pays 60% |
| Emergency Room | $150 copay, and plan pays 80% | |
| Urgent Care | $25 copay, and plan pays 100% | Plan pays 60% |
| Outpatient Radiology | Plan pays 80% | Plan pays 60% |
| Independent Laboratory | Plan pays 80% | Plan pays 60% |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | $20 copay, and plan pays 100% | Plan pays 60% |
| Pharmacy Formulary | Performance | |
| Retail Pharmacy Customer Share | Retail (per 30-day supply): Generic: You pay $15 Preferred Brand: You pay $30 Non-Preferred Brand: You pay $50 | Retail: You pay 50% Your plan pays 50% |
| Home Delivery Pharmacy Customer Share | 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 | 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.