Your Medical Benefits
Medical
Group # 00657005
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 Plan - OAP Buy Up | Open Access Plus Plan - OAP Base | OAP HDHPQ Plan - HDHPQ OAP | |
|---|---|---|---|
| Plan Coinsurance | |||
| In-Network | Plan pays 80% | Plan pays 70% | Plan pays 70% |
| Out-Of-Network | Plan pays 50% | Plan pays 50% | Plan pays 50% |
| Individual Deductible | |||
| In-Network | Individual: $2,000 | Individual: $4,000 | Individual - Employee Only: $6,500 Individual - within a Family: $6,500 |
| Out-Of-Network | Individual: $4,000 | Individual: $8,000 | Individual - Employee Only: $10,000 Individual - within a Family: $10,000 |
| Family Deductible | |||
| In-Network | Family: $4,000 | Family: $8,000 | Family Maximum: $13,000 |
| Out-Of-Network | Family: $8,000 | Family: $16,000 | Family Maximum: $20,000 |
| Individual Out-of-Pocket | |||
| In-Network | Individual: $5,000 | Individual: $7,000 | Individual - Employee Only: $8,050 Individual - within a Family: $8,050 |
| Out-Of-Network | Individual: $10,000 | Individual: $14,000 | Individual - Employee Only: $20,000 Individual - within a Family: $20,000 |
| Family Out-of-Pocket | |||
| In-Network | Family: $10,000 | Family: $14,000 | Family Maximum: $16,100 |
| Out-Of-Network | Family: $20,000 | Family: $28,000 | Family Maximum: $40,000 |
| Primary Care Office Visit | |||
| In-Network | $20 copay, and plan pays 100% | $30 copay, and plan pays 100% | Plan pays 70% |
| Out-Of-Network | Plan pays 50% | Plan pays 50% | Plan pays 50% |
| Specialist Care Office Visit | |||
| In-Network | $40 copay, and plan pays 100% | $60 copay, and plan pays 100% | Plan pays 70% |
| Out-Of-Network | Plan pays 50% | Plan pays 50% | Plan pays 50% |
| Emergency Room | |||
| $500 copay, and plan pays 80% | $500 copay, and plan pays 70% | Plan pays 70% | |
| Urgent Care | |||
| In-Network | $50 copay, and plan pays 100% | $50 copay, and plan pays 100% | Plan pays 70% |
| Out-Of-Network | Plan pays 50% | Plan pays 50% | Plan pays 50% |
| Outpatient Radiology | |||
| In-Network | Plan pays 80% | Plan pays 70% | Plan pays 70% |
| Out-Of-Network | Plan pays 50% | Plan pays 50% | Plan pays 50% |
| Independent Laboratory | |||
| In-Network | Plan pays 80% | Plan pays 70% | Plan pays 70% |
| Out-Of-Network | Plan pays 50% | Plan pays 50% | Plan pays 50% |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | |||
| In-Network | $40 copay, and plan pays 100% | $60 copay, and plan pays 100% | Plan pays 70% |
| Out-Of-Network | Plan pays 50% | Plan pays 50% | Plan pays 50% |
| Pharmacy Formulary | |||
| Advantage | Advantage | Advantage | |
| Retail Pharmacy Customer Share | |||
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $35 Non-Preferred Brand: You pay $70 | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $35 Non-Preferred Brand: You pay $70 | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $35 Non-Preferred Brand: You pay $70 |
| Out-Of-Network | Not Covered for all benefits | Not Covered for all benefits | Not Covered for all benefits |
| Home Delivery Pharmacy Customer Share | |||
| In-Network | Retail and Home Delivery (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $105 Non-Preferred Brand: You pay $210 | Retail and Home Delivery (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $105 Non-Preferred Brand: You pay $210 | Retail and Home Delivery (per 90-day supply): Generic: You pay $25 Preferred Brand: You pay $88 Non-Preferred Brand: You pay $175 |
| Out-Of-Network | Not Covered for all benefits | Not Covered for all benefits | Not Covered for all benefits |
Plan Coinsurance
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
Individual Deductible
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Individual: $2,000 |
| Out-of-Network | Individual: $4,000 |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Individual: $4,000 |
| Out-of-Network | Individual: $8,000 |
| OAP HDHPQ Plan - HDHPQ OAP | |
|---|---|
| In-Network | Individual - Employee Only: $6,500 Individual - within a Family: $6,500 |
| Out-of-Network | Individual - Employee Only: $10,000 Individual - within a Family: $10,000 |
Family Deductible
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Family: $4,000 |
| Out-of-Network | Family: $8,000 |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Family: $8,000 |
| Out-of-Network | Family: $16,000 |
| OAP HDHPQ Plan - HDHPQ OAP | |
|---|---|
| In-Network | Family Maximum: $13,000 |
| Out-of-Network | Family Maximum: $20,000 |
Individual Out-of-Pocket
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Individual: $5,000 |
| Out-of-Network | Individual: $10,000 |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Individual: $7,000 |
| Out-of-Network | Individual: $14,000 |
| OAP HDHPQ Plan - HDHPQ OAP | |
|---|---|
| In-Network | Individual - Employee Only: $8,050 Individual - within a Family: $8,050 |
| Out-of-Network | Individual - Employee Only: $20,000 Individual - within a Family: $20,000 |
Family Out-of-Pocket
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Family: $10,000 |
| Out-of-Network | Family: $20,000 |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Family: $14,000 |
| Out-of-Network | Family: $28,000 |
| OAP HDHPQ Plan - HDHPQ OAP | |
|---|---|
| In-Network | Family Maximum: $16,100 |
| Out-of-Network | Family Maximum: $40,000 |
Primary Care Office Visit
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | $20 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
Specialist Care Office Visit
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | $40 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | $60 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
Emergency Room
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| $500 copay, and plan pays 80% |
| Open Access Plus Plan - OAP Base | |
|---|---|
| $500 copay, and plan pays 70% |
| OAP HDHPQ Plan - HDHPQ OAP | |
|---|---|
| Plan pays 70% |
Urgent Care
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | $50 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | $50 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
Outpatient Radiology
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
Independent Laboratory
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
Outpatient Physical, Speech, Hearing, and Occupational Therapy
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | $40 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | $60 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
Pharmacy Formulary
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| Advantage |
| Open Access Plus Plan - OAP Base | |
|---|---|
| Advantage |
| OAP HDHPQ Plan - HDHPQ OAP | |
|---|---|
| Advantage |
Retail Pharmacy Customer Share
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $35 Non-Preferred Brand: You pay $70 |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $35 Non-Preferred Brand: You pay $70 |
| OAP HDHPQ Plan - HDHPQ OAP | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $35 Non-Preferred Brand: You pay $70 |
Home Delivery Pharmacy Customer Share
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Retail and Home Delivery (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $105 Non-Preferred Brand: You pay $210 |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Retail and Home Delivery (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $105 Non-Preferred Brand: You pay $210 |
| OAP HDHPQ Plan - HDHPQ OAP | |
|---|---|
| In-Network | Retail and Home Delivery (per 90-day supply): Generic: You pay $25 Preferred Brand: You pay $88 Non-Preferred Brand: You pay $175 |
All plans have exclusions and limitations. For a summary of these exclusions and limitations, view the Summary of Benefits and Coverage.
Medical
Group # 00657005
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 Plan - OAP Buy Up | Open Access Plus Plan - OAP Base | OAP HDHPQ Plan - HDHPQ OAP | |
|---|---|---|---|
| Plan Coinsurance | |||
| In-Network | Plan pays 80% | Plan pays 70% | Plan pays 70% |
| Out-Of-Network | Plan pays 50% | Plan pays 50% | Plan pays 50% |
| Individual Deductible | |||
| In-Network | Individual: $2,000 | Individual: $4,000 | Individual - Employee Only: $6,500 Individual - within a Family: $6,500 |
| Out-Of-Network | Individual: $4,000 | Individual: $8,000 | Individual - Employee Only: $10,000 Individual - within a Family: $10,000 |
| Family Deductible | |||
| In-Network | Family: $4,000 | Family: $8,000 | Family Maximum: $13,000 |
| Out-Of-Network | Family: $8,000 | Family: $16,000 | Family Maximum: $20,000 |
| Individual Out-of-Pocket | |||
| In-Network | Individual: $5,000 | Individual: $7,000 | Individual - Employee Only: $8,050 Individual - within a Family: $8,050 |
| Out-Of-Network | Individual: $10,000 | Individual: $14,000 | Individual - Employee Only: $20,000 Individual - within a Family: $20,000 |
| Family Out-of-Pocket | |||
| In-Network | Family: $10,000 | Family: $14,000 | Family Maximum: $16,100 |
| Out-Of-Network | Family: $20,000 | Family: $28,000 | Family Maximum: $40,000 |
| Primary Care Office Visit | |||
| In-Network | $20 copay, and plan pays 100% | $30 copay, and plan pays 100% | Plan pays 70% |
| Out-Of-Network | Plan pays 50% | Plan pays 50% | Plan pays 50% |
| Specialist Care Office Visit | |||
| In-Network | $40 copay, and plan pays 100% | $60 copay, and plan pays 100% | Plan pays 70% |
| Out-Of-Network | Plan pays 50% | Plan pays 50% | Plan pays 50% |
| Emergency Room | |||
| $500 copay, and plan pays 80% | $500 copay, and plan pays 70% | Plan pays 70% | |
| Urgent Care | |||
| In-Network | $50 copay, and plan pays 100% | $50 copay, and plan pays 100% | Plan pays 70% |
| Out-Of-Network | Plan pays 50% | Plan pays 50% | Plan pays 50% |
| Outpatient Radiology | |||
| In-Network | Plan pays 80% | Plan pays 70% | Plan pays 70% |
| Out-Of-Network | Plan pays 50% | Plan pays 50% | Plan pays 50% |
| Independent Laboratory | |||
| In-Network | Plan pays 80% | Plan pays 70% | Plan pays 70% |
| Out-Of-Network | Plan pays 50% | Plan pays 50% | Plan pays 50% |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | |||
| In-Network | $40 copay, and plan pays 100% | $60 copay, and plan pays 100% | Plan pays 70% |
| Out-Of-Network | Plan pays 50% | Plan pays 50% | Plan pays 50% |
| Pharmacy Formulary | |||
| Advantage | Advantage | Advantage | |
| Retail Pharmacy Customer Share | |||
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $35 Non-Preferred Brand: You pay $70 | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $35 Non-Preferred Brand: You pay $70 | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $35 Non-Preferred Brand: You pay $70 |
| Out-Of-Network | Not Covered for all benefits | Not Covered for all benefits | Not Covered for all benefits |
| Home Delivery Pharmacy Customer Share | |||
| In-Network | Retail and Home Delivery (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $105 Non-Preferred Brand: You pay $210 | Retail and Home Delivery (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $105 Non-Preferred Brand: You pay $210 | Retail and Home Delivery (per 90-day supply): Generic: You pay $25 Preferred Brand: You pay $88 Non-Preferred Brand: You pay $175 |
| Out-Of-Network | Not Covered for all benefits | Not Covered for all benefits | Not Covered for all benefits |
Plan Coinsurance
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
Individual Deductible
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Individual: $2,000 |
| Out-of-Network | Individual: $4,000 |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Individual: $4,000 |
| Out-of-Network | Individual: $8,000 |
| OAP HDHPQ Plan - HDHPQ OAP | |
|---|---|
| In-Network | Individual - Employee Only: $6,500 Individual - within a Family: $6,500 |
| Out-of-Network | Individual - Employee Only: $10,000 Individual - within a Family: $10,000 |
Family Deductible
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Family: $4,000 |
| Out-of-Network | Family: $8,000 |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Family: $8,000 |
| Out-of-Network | Family: $16,000 |
| OAP HDHPQ Plan - HDHPQ OAP | |
|---|---|
| In-Network | Family Maximum: $13,000 |
| Out-of-Network | Family Maximum: $20,000 |
Individual Out-of-Pocket
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Individual: $5,000 |
| Out-of-Network | Individual: $10,000 |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Individual: $7,000 |
| Out-of-Network | Individual: $14,000 |
| OAP HDHPQ Plan - HDHPQ OAP | |
|---|---|
| In-Network | Individual - Employee Only: $8,050 Individual - within a Family: $8,050 |
| Out-of-Network | Individual - Employee Only: $20,000 Individual - within a Family: $20,000 |
Family Out-of-Pocket
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Family: $10,000 |
| Out-of-Network | Family: $20,000 |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Family: $14,000 |
| Out-of-Network | Family: $28,000 |
| OAP HDHPQ Plan - HDHPQ OAP | |
|---|---|
| In-Network | Family Maximum: $16,100 |
| Out-of-Network | Family Maximum: $40,000 |
Primary Care Office Visit
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | $20 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
Specialist Care Office Visit
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | $40 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | $60 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
Emergency Room
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| $500 copay, and plan pays 80% |
| Open Access Plus Plan - OAP Base | |
|---|---|
| $500 copay, and plan pays 70% |
| OAP HDHPQ Plan - HDHPQ OAP | |
|---|---|
| Plan pays 70% |
Urgent Care
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | $50 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | $50 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
Outpatient Radiology
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
Independent Laboratory
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
Outpatient Physical, Speech, Hearing, and Occupational Therapy
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | $40 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | $60 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
Pharmacy Formulary
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| Advantage |
| Open Access Plus Plan - OAP Base | |
|---|---|
| Advantage |
| OAP HDHPQ Plan - HDHPQ OAP | |
|---|---|
| Advantage |
Retail Pharmacy Customer Share
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $35 Non-Preferred Brand: You pay $70 |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $35 Non-Preferred Brand: You pay $70 |
| OAP HDHPQ Plan - HDHPQ OAP | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $35 Non-Preferred Brand: You pay $70 |
Home Delivery Pharmacy Customer Share
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Retail and Home Delivery (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $105 Non-Preferred Brand: You pay $210 |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Retail and Home Delivery (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $105 Non-Preferred Brand: You pay $210 |
| OAP HDHPQ Plan - HDHPQ OAP | |
|---|---|
| In-Network | Retail and Home Delivery (per 90-day supply): Generic: You pay $25 Preferred Brand: You pay $88 Non-Preferred Brand: You pay $175 |
All plans have exclusions and limitations. For a summary of these exclusions and limitations, view the Summary of Benefits and Coverage.