Your Medical Benefits
Open Access Plus Plan - OAP BuyUp
Benefit Summary
Group # 00634554
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 Plan - OAP BuyUp | |
| Plan Coinsurance | Plan pays 100% | Plan pays 60% |
| Individual Deductible | Individual: $750 | Individual: $2,500 |
| Family Deductible | Family: $1,500 | Family: $7,500 |
| Individual Out-of-Pocket | Individual: $1,250 | Individual: $28,000 |
| Family Out-of-Pocket | Family: $3,750 | Family: $56,000 |
| Primary Care Office Visit | $25 copay, and plan pays 100% | Plan pays 60% |
| Specialist Care Office Visit | $45 copay, and plan pays 100% | Plan pays 60% |
| Emergency Room | $400 copay, and plan pays 100% | |
| Urgent Care | $25 copay, and plan pays 100% | $25 copay, and plan pays 100% |
| Outpatient Radiology | Plan pays 100% | Plan pays 60% |
| Independent Laboratory | Plan pays 100% | Plan pays 60% |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | Plan pays 100% | Plan pays 60% |
| Pharmacy Formulary | Advantage | |
| Retail Pharmacy Customer Share | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $35 Non-Preferred Brand: You pay $75 Specialty: You pay $150 Retail (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $105 Non-Preferred Brand: You pay $225 | Retail: You pay 50% Your plan pays 50% |
| Home Delivery Pharmacy Customer Share | Home Delivery (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $105 Non-Preferred Brand: You pay $225 Specialty: You pay $450 | Home Delivery: Same as Retail Out-of-Network |
All plans have exclusions and limitations. For a summary of these exclusions and limitations, view the Summary of Benefits and Coverage.
Benefit Summary
Group # 00634554
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 Plan - OAP BuyUp | |
| Plan Coinsurance | Plan pays 100% | Plan pays 60% |
| Individual Deductible | Individual: $750 | Individual: $2,500 |
| Family Deductible | Family: $1,500 | Family: $7,500 |
| Individual Out-of-Pocket | Individual: $1,250 | Individual: $28,000 |
| Family Out-of-Pocket | Family: $3,750 | Family: $56,000 |
| Primary Care Office Visit | $25 copay, and plan pays 100% | Plan pays 60% |
| Specialist Care Office Visit | $45 copay, and plan pays 100% | Plan pays 60% |
| Emergency Room | $400 copay, and plan pays 100% | |
| Urgent Care | $25 copay, and plan pays 100% | $25 copay, and plan pays 100% |
| Outpatient Radiology | Plan pays 100% | Plan pays 60% |
| Independent Laboratory | Plan pays 100% | Plan pays 60% |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | Plan pays 100% | Plan pays 60% |
| Pharmacy Formulary | Advantage | |
| Retail Pharmacy Customer Share | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $35 Non-Preferred Brand: You pay $75 Specialty: You pay $150 Retail (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $105 Non-Preferred Brand: You pay $225 | Retail: You pay 50% Your plan pays 50% |
| Home Delivery Pharmacy Customer Share | Home Delivery (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $105 Non-Preferred Brand: You pay $225 Specialty: You pay $450 | Home Delivery: Same as Retail Out-of-Network |
All plans have exclusions and limitations. For a summary of these exclusions and limitations, view the Summary of Benefits and Coverage.