Your Medical Benefits
Medical
Group # 00635670
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 Mid | OAP HDHPQ Plan - OAP Base | |
---|---|---|---|
Plan Coinsurance | |||
In-Network | Plan pays 80% | Plan pays 80% | Plan pays 100% |
Out-Of-Network | Plan pays 60% | Plan pays 60% | Plan pays 50% |
Individual Deductible | |||
In-Network | Individual: $2,000 | Individual: $3,000 | Individual - Employee Only: $4,000 Individual - within a Family: $4,000 |
Out-Of-Network | Individual: $5,000 | Individual: $6,000 | Individual - Employee Only: $10,000 Individual - within a Family: $10,000 |
Family Deductible | |||
In-Network | Family: $4,000 | Family: $6,000 | Family Maximum: $8,000 |
Out-Of-Network | Family: $15,000 | Family: $12,000 | Family Maximum: $20,000 |
Individual Out-of-Pocket | |||
In-Network | Individual: $5,000 | Individual: $6,000 | Individual - Employee Only: $4,000 Individual - within a Family: $4,000 |
Out-Of-Network | Individual: $11,000 | Individual: $12,000 | Individual - Employee Only: $22,700 Individual - within a Family: $22,700 |
Family Out-of-Pocket | |||
In-Network | Family: $10,000 | Family: $12,000 | Family Maximum: $8,000 |
Out-Of-Network | Family: $33,000 | Family: $24,000 | Family Maximum: $68,100 |
Primary Care Office Visit | |||
In-Network | $30 copay, and plan pays 100% | $40 copay, and plan pays 100% | Plan pays 100% |
Out-Of-Network | Plan pays 60% | Plan pays 60% | Plan pays 50% |
Specialist Care Office Visit | |||
In-Network | $75 copay, and plan pays 100% | $75 copay, and plan pays 100% | Plan pays 100% |
Out-Of-Network | Plan pays 60% | Plan pays 60% | Plan pays 50% |
Emergency Room | |||
$500 copay, and plan pays 80% | $500 copay, and plan pays 80% | Plan pays 100% | |
Urgent Care | |||
In-Network | $60 copay, and plan pays 100% | $75 copay, and plan pays 100% | Plan pays 100% |
Out-Of-Network | Plan pays 60% | Plan pays 60% | Plan pays 50% |
Outpatient Radiology | |||
In-Network | Plan pays 80% | Plan pays 80% | Plan pays 100% |
Out-Of-Network | Plan pays 60% | Plan pays 60% | Plan pays 50% |
Independent Laboratory | |||
In-Network | Plan pays 80% | Plan pays 80% | Plan pays 100% |
Out-Of-Network | Plan pays 60% | Plan pays 60% | Plan pays 50% |
Outpatient Physical, Speech, Hearing, and Occupational Therapy | |||
In-Network | $75 copay, and plan pays 100% | $75 copay, and plan pays 100% | Plan pays 100% |
Out-Of-Network | Plan pays 60% | Plan pays 60% | Plan pays 50% |
Pharmacy Formulary | |||
Advantage | Advantage | Advantage | |
Retail Pharmacy Customer Share | |||
In-Network | Retail (per 30-day supply): Generic: You pay $0 Preferred Brand: You pay $30 Non-Preferred Brand: You pay $40 Retail (per 90-day supply): Generic: You pay $0 Preferred Brand: You pay $90 Non-Preferred Brand: You pay $120 | Retail (per 30-day supply): Generic: You pay $0 Preferred Brand: You pay $35 Non-Preferred Brand: You pay $45 Retail (per 90-day supply): Generic: You pay $0 Preferred Brand: You pay $105 Non-Preferred Brand: You pay $135 | Retail: You pay 0% Your plan pays 100% |
Out-Of-Network | Retail: You pay 60% Your plan pays 40% | Not Covered for all benefits | Not Covered for all benefits |
Home Delivery Pharmacy Customer Share | |||
In-Network | Home Delivery (per 90-day supply): Generic: You pay $0 Preferred Brand: You pay $90 Non-Preferred Brand: You pay $120 | Home Delivery (per 90-day supply): Generic: You pay $0 Preferred Brand: You pay $105 Non-Preferred Brand: You pay $135 | Home Delivery: You pay 0% Your plan pays 100% |
Out-Of-Network | Home Delivery: Not Covered | Not Covered for all benefits | Not Covered for all benefits |
Open Access Plus Plan - OAP Buy Up | |
---|---|
In-Network | Plan pays 80% |
Out-of-Network | Plan pays 60% |
Open Access Plus Plan - OAP Mid | |
---|---|
In-Network | Plan pays 80% |
Out-of-Network | Plan pays 60% |
OAP HDHPQ Plan - OAP Base | |
---|---|
In-Network | Plan pays 100% |
Out-of-Network | Plan pays 50% |
Open Access Plus Plan - OAP Buy Up | |
---|---|
In-Network | Individual: $2,000 |
Out-of-Network | Individual: $5,000 |
Open Access Plus Plan - OAP Mid | |
---|---|
In-Network | Individual: $3,000 |
Out-of-Network | Individual: $6,000 |
OAP HDHPQ Plan - OAP Base | |
---|---|
In-Network | Individual - Employee Only: $4,000 Individual - within a Family: $4,000 |
Out-of-Network | Individual - Employee Only: $10,000 Individual - within a Family: $10,000 |
Open Access Plus Plan - OAP Buy Up | |
---|---|
In-Network | Family: $4,000 |
Out-of-Network | Family: $15,000 |
Open Access Plus Plan - OAP Mid | |
---|---|
In-Network | Family: $6,000 |
Out-of-Network | Family: $12,000 |
OAP HDHPQ Plan - OAP Base | |
---|---|
In-Network | Family Maximum: $8,000 |
Out-of-Network | Family Maximum: $20,000 |
Open Access Plus Plan - OAP Buy Up | |
---|---|
In-Network | Individual: $5,000 |
Out-of-Network | Individual: $11,000 |
Open Access Plus Plan - OAP Mid | |
---|---|
In-Network | Individual: $6,000 |
Out-of-Network | Individual: $12,000 |
OAP HDHPQ Plan - OAP Base | |
---|---|
In-Network | Individual - Employee Only: $4,000 Individual - within a Family: $4,000 |
Out-of-Network | Individual - Employee Only: $22,700 Individual - within a Family: $22,700 |
Open Access Plus Plan - OAP Buy Up | |
---|---|
In-Network | Family: $10,000 |
Out-of-Network | Family: $33,000 |
Open Access Plus Plan - OAP Mid | |
---|---|
In-Network | Family: $12,000 |
Out-of-Network | Family: $24,000 |
OAP HDHPQ Plan - OAP Base | |
---|---|
In-Network | Family Maximum: $8,000 |
Out-of-Network | Family Maximum: $68,100 |
Open Access Plus Plan - OAP Buy Up | |
---|---|
In-Network | $30 copay, and plan pays 100% |
Out-of-Network | Plan pays 60% |
Open Access Plus Plan - OAP Mid | |
---|---|
In-Network | $40 copay, and plan pays 100% |
Out-of-Network | Plan pays 60% |
OAP HDHPQ Plan - OAP Base | |
---|---|
In-Network | Plan pays 100% |
Out-of-Network | Plan pays 50% |
Open Access Plus Plan - OAP Buy Up | |
---|---|
In-Network | $75 copay, and plan pays 100% |
Out-of-Network | Plan pays 60% |
Open Access Plus Plan - OAP Mid | |
---|---|
In-Network | $75 copay, and plan pays 100% |
Out-of-Network | Plan pays 60% |
OAP HDHPQ Plan - OAP Base | |
---|---|
In-Network | Plan pays 100% |
Out-of-Network | Plan pays 50% |
Open Access Plus Plan - OAP Buy Up | |
---|---|
$500 copay, and plan pays 80% |
Open Access Plus Plan - OAP Mid | |
---|---|
$500 copay, and plan pays 80% |
OAP HDHPQ Plan - OAP Base | |
---|---|
Plan pays 100% |
Open Access Plus Plan - OAP Buy Up | |
---|---|
In-Network | $60 copay, and plan pays 100% |
Out-of-Network | Plan pays 60% |
Open Access Plus Plan - OAP Mid | |
---|---|
In-Network | $75 copay, and plan pays 100% |
Out-of-Network | Plan pays 60% |
OAP HDHPQ Plan - OAP Base | |
---|---|
In-Network | Plan pays 100% |
Out-of-Network | Plan pays 50% |
Open Access Plus Plan - OAP Buy Up | |
---|---|
In-Network | Plan pays 80% |
Out-of-Network | Plan pays 60% |
Open Access Plus Plan - OAP Mid | |
---|---|
In-Network | Plan pays 80% |
Out-of-Network | Plan pays 60% |
OAP HDHPQ Plan - OAP Base | |
---|---|
In-Network | Plan pays 100% |
Out-of-Network | Plan pays 50% |
Open Access Plus Plan - OAP Buy Up | |
---|---|
In-Network | Plan pays 80% |
Out-of-Network | Plan pays 60% |
Open Access Plus Plan - OAP Mid | |
---|---|
In-Network | Plan pays 80% |
Out-of-Network | Plan pays 60% |
OAP HDHPQ Plan - OAP Base | |
---|---|
In-Network | Plan pays 100% |
Out-of-Network | Plan pays 50% |
Open Access Plus Plan - OAP Buy Up | |
---|---|
In-Network | $75 copay, and plan pays 100% |
Out-of-Network | Plan pays 60% |
Open Access Plus Plan - OAP Mid | |
---|---|
In-Network | $75 copay, and plan pays 100% |
Out-of-Network | Plan pays 60% |
OAP HDHPQ Plan - OAP Base | |
---|---|
In-Network | Plan pays 100% |
Out-of-Network | Plan pays 50% |
Open Access Plus Plan - OAP Buy Up | |
---|---|
Advantage |
Open Access Plus Plan - OAP Mid | |
---|---|
Advantage |
OAP HDHPQ Plan - OAP Base | |
---|---|
Advantage |
Open Access Plus Plan - OAP Buy Up | |
---|---|
In-Network | Retail (per 30-day supply): Generic: You pay $0 Preferred Brand: You pay $30 Non-Preferred Brand: You pay $40 Retail (per 90-day supply): Generic: You pay $0 Preferred Brand: You pay $90 Non-Preferred Brand: You pay $120 |
Out-of-Network | Retail: You pay 60% Your plan pays 40% |
Open Access Plus Plan - OAP Mid | |
---|---|
In-Network | Retail (per 30-day supply): Generic: You pay $0 Preferred Brand: You pay $35 Non-Preferred Brand: You pay $45 Retail (per 90-day supply): Generic: You pay $0 Preferred Brand: You pay $105 Non-Preferred Brand: You pay $135 |
OAP HDHPQ Plan - OAP Base | |
---|---|
In-Network | Retail: You pay 0% Your plan pays 100% |
Open Access Plus Plan - OAP Buy Up | |
---|---|
In-Network | Home Delivery (per 90-day supply): Generic: You pay $0 Preferred Brand: You pay $90 Non-Preferred Brand: You pay $120 |
Out-of-Network | Home Delivery: Not Covered |
Open Access Plus Plan - OAP Mid | |
---|---|
In-Network | Home Delivery (per 90-day supply): Generic: You pay $0 Preferred Brand: You pay $105 Non-Preferred Brand: You pay $135 |
OAP HDHPQ Plan - OAP Base | |
---|---|
In-Network | Home Delivery: You pay 0% Your plan pays 100% |
All plans have exclusions and limitations. For a summary of these exclusions and limitations, view the Summary of Benefits and Coverage.
Medical
Group # 00635670
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 Mid | OAP HDHPQ Plan - OAP Base | |
---|---|---|---|
Plan Coinsurance | |||
In-Network | Plan pays 80% | Plan pays 80% | Plan pays 100% |
Out-Of-Network | Plan pays 60% | Plan pays 60% | Plan pays 50% |
Individual Deductible | |||
In-Network | Individual: $2,000 | Individual: $3,000 | Individual - Employee Only: $4,000 Individual - within a Family: $4,000 |
Out-Of-Network | Individual: $5,000 | Individual: $6,000 | Individual - Employee Only: $10,000 Individual - within a Family: $10,000 |
Family Deductible | |||
In-Network | Family: $4,000 | Family: $6,000 | Family Maximum: $8,000 |
Out-Of-Network | Family: $15,000 | Family: $12,000 | Family Maximum: $20,000 |
Individual Out-of-Pocket | |||
In-Network | Individual: $5,000 | Individual: $6,000 | Individual - Employee Only: $4,000 Individual - within a Family: $4,000 |
Out-Of-Network | Individual: $11,000 | Individual: $12,000 | Individual - Employee Only: $22,700 Individual - within a Family: $22,700 |
Family Out-of-Pocket | |||
In-Network | Family: $10,000 | Family: $12,000 | Family Maximum: $8,000 |
Out-Of-Network | Family: $33,000 | Family: $24,000 | Family Maximum: $68,100 |
Primary Care Office Visit | |||
In-Network | $30 copay, and plan pays 100% | $40 copay, and plan pays 100% | Plan pays 100% |
Out-Of-Network | Plan pays 60% | Plan pays 60% | Plan pays 50% |
Specialist Care Office Visit | |||
In-Network | $75 copay, and plan pays 100% | $75 copay, and plan pays 100% | Plan pays 100% |
Out-Of-Network | Plan pays 60% | Plan pays 60% | Plan pays 50% |
Emergency Room | |||
$500 copay, and plan pays 80% | $500 copay, and plan pays 80% | Plan pays 100% | |
Urgent Care | |||
In-Network | $60 copay, and plan pays 100% | $75 copay, and plan pays 100% | Plan pays 100% |
Out-Of-Network | Plan pays 60% | Plan pays 60% | Plan pays 50% |
Outpatient Radiology | |||
In-Network | Plan pays 80% | Plan pays 80% | Plan pays 100% |
Out-Of-Network | Plan pays 60% | Plan pays 60% | Plan pays 50% |
Independent Laboratory | |||
In-Network | Plan pays 80% | Plan pays 80% | Plan pays 100% |
Out-Of-Network | Plan pays 60% | Plan pays 60% | Plan pays 50% |
Outpatient Physical, Speech, Hearing, and Occupational Therapy | |||
In-Network | $75 copay, and plan pays 100% | $75 copay, and plan pays 100% | Plan pays 100% |
Out-Of-Network | Plan pays 60% | Plan pays 60% | Plan pays 50% |
Pharmacy Formulary | |||
Advantage | Advantage | Advantage | |
Retail Pharmacy Customer Share | |||
In-Network | Retail (per 30-day supply): Generic: You pay $0 Preferred Brand: You pay $30 Non-Preferred Brand: You pay $40 Retail (per 90-day supply): Generic: You pay $0 Preferred Brand: You pay $90 Non-Preferred Brand: You pay $120 | Retail (per 30-day supply): Generic: You pay $0 Preferred Brand: You pay $35 Non-Preferred Brand: You pay $45 Retail (per 90-day supply): Generic: You pay $0 Preferred Brand: You pay $105 Non-Preferred Brand: You pay $135 | Retail: You pay 0% Your plan pays 100% |
Out-Of-Network | Retail: You pay 60% Your plan pays 40% | Not Covered for all benefits | Not Covered for all benefits |
Home Delivery Pharmacy Customer Share | |||
In-Network | Home Delivery (per 90-day supply): Generic: You pay $0 Preferred Brand: You pay $90 Non-Preferred Brand: You pay $120 | Home Delivery (per 90-day supply): Generic: You pay $0 Preferred Brand: You pay $105 Non-Preferred Brand: You pay $135 | Home Delivery: You pay 0% Your plan pays 100% |
Out-Of-Network | Home Delivery: Not Covered | Not Covered for all benefits | Not Covered for all benefits |
Open Access Plus Plan - OAP Buy Up | |
---|---|
In-Network | Plan pays 80% |
Out-of-Network | Plan pays 60% |
Open Access Plus Plan - OAP Mid | |
---|---|
In-Network | Plan pays 80% |
Out-of-Network | Plan pays 60% |
OAP HDHPQ Plan - OAP Base | |
---|---|
In-Network | Plan pays 100% |
Out-of-Network | Plan pays 50% |
Open Access Plus Plan - OAP Buy Up | |
---|---|
In-Network | Individual: $2,000 |
Out-of-Network | Individual: $5,000 |
Open Access Plus Plan - OAP Mid | |
---|---|
In-Network | Individual: $3,000 |
Out-of-Network | Individual: $6,000 |
OAP HDHPQ Plan - OAP Base | |
---|---|
In-Network | Individual - Employee Only: $4,000 Individual - within a Family: $4,000 |
Out-of-Network | Individual - Employee Only: $10,000 Individual - within a Family: $10,000 |
Open Access Plus Plan - OAP Buy Up | |
---|---|
In-Network | Family: $4,000 |
Out-of-Network | Family: $15,000 |
Open Access Plus Plan - OAP Mid | |
---|---|
In-Network | Family: $6,000 |
Out-of-Network | Family: $12,000 |
OAP HDHPQ Plan - OAP Base | |
---|---|
In-Network | Family Maximum: $8,000 |
Out-of-Network | Family Maximum: $20,000 |
Open Access Plus Plan - OAP Buy Up | |
---|---|
In-Network | Individual: $5,000 |
Out-of-Network | Individual: $11,000 |
Open Access Plus Plan - OAP Mid | |
---|---|
In-Network | Individual: $6,000 |
Out-of-Network | Individual: $12,000 |
OAP HDHPQ Plan - OAP Base | |
---|---|
In-Network | Individual - Employee Only: $4,000 Individual - within a Family: $4,000 |
Out-of-Network | Individual - Employee Only: $22,700 Individual - within a Family: $22,700 |
Open Access Plus Plan - OAP Buy Up | |
---|---|
In-Network | Family: $10,000 |
Out-of-Network | Family: $33,000 |
Open Access Plus Plan - OAP Mid | |
---|---|
In-Network | Family: $12,000 |
Out-of-Network | Family: $24,000 |
OAP HDHPQ Plan - OAP Base | |
---|---|
In-Network | Family Maximum: $8,000 |
Out-of-Network | Family Maximum: $68,100 |
Open Access Plus Plan - OAP Buy Up | |
---|---|
In-Network | $30 copay, and plan pays 100% |
Out-of-Network | Plan pays 60% |
Open Access Plus Plan - OAP Mid | |
---|---|
In-Network | $40 copay, and plan pays 100% |
Out-of-Network | Plan pays 60% |
OAP HDHPQ Plan - OAP Base | |
---|---|
In-Network | Plan pays 100% |
Out-of-Network | Plan pays 50% |
Open Access Plus Plan - OAP Buy Up | |
---|---|
In-Network | $75 copay, and plan pays 100% |
Out-of-Network | Plan pays 60% |
Open Access Plus Plan - OAP Mid | |
---|---|
In-Network | $75 copay, and plan pays 100% |
Out-of-Network | Plan pays 60% |
OAP HDHPQ Plan - OAP Base | |
---|---|
In-Network | Plan pays 100% |
Out-of-Network | Plan pays 50% |
Open Access Plus Plan - OAP Buy Up | |
---|---|
$500 copay, and plan pays 80% |
Open Access Plus Plan - OAP Mid | |
---|---|
$500 copay, and plan pays 80% |
OAP HDHPQ Plan - OAP Base | |
---|---|
Plan pays 100% |
Open Access Plus Plan - OAP Buy Up | |
---|---|
In-Network | $60 copay, and plan pays 100% |
Out-of-Network | Plan pays 60% |
Open Access Plus Plan - OAP Mid | |
---|---|
In-Network | $75 copay, and plan pays 100% |
Out-of-Network | Plan pays 60% |
OAP HDHPQ Plan - OAP Base | |
---|---|
In-Network | Plan pays 100% |
Out-of-Network | Plan pays 50% |
Open Access Plus Plan - OAP Buy Up | |
---|---|
In-Network | Plan pays 80% |
Out-of-Network | Plan pays 60% |
Open Access Plus Plan - OAP Mid | |
---|---|
In-Network | Plan pays 80% |
Out-of-Network | Plan pays 60% |
OAP HDHPQ Plan - OAP Base | |
---|---|
In-Network | Plan pays 100% |
Out-of-Network | Plan pays 50% |
Open Access Plus Plan - OAP Buy Up | |
---|---|
In-Network | Plan pays 80% |
Out-of-Network | Plan pays 60% |
Open Access Plus Plan - OAP Mid | |
---|---|
In-Network | Plan pays 80% |
Out-of-Network | Plan pays 60% |
OAP HDHPQ Plan - OAP Base | |
---|---|
In-Network | Plan pays 100% |
Out-of-Network | Plan pays 50% |
Open Access Plus Plan - OAP Buy Up | |
---|---|
In-Network | $75 copay, and plan pays 100% |
Out-of-Network | Plan pays 60% |
Open Access Plus Plan - OAP Mid | |
---|---|
In-Network | $75 copay, and plan pays 100% |
Out-of-Network | Plan pays 60% |
OAP HDHPQ Plan - OAP Base | |
---|---|
In-Network | Plan pays 100% |
Out-of-Network | Plan pays 50% |
Open Access Plus Plan - OAP Buy Up | |
---|---|
Advantage |
Open Access Plus Plan - OAP Mid | |
---|---|
Advantage |
OAP HDHPQ Plan - OAP Base | |
---|---|
Advantage |
Open Access Plus Plan - OAP Buy Up | |
---|---|
In-Network | Retail (per 30-day supply): Generic: You pay $0 Preferred Brand: You pay $30 Non-Preferred Brand: You pay $40 Retail (per 90-day supply): Generic: You pay $0 Preferred Brand: You pay $90 Non-Preferred Brand: You pay $120 |
Out-of-Network | Retail: You pay 60% Your plan pays 40% |
Open Access Plus Plan - OAP Mid | |
---|---|
In-Network | Retail (per 30-day supply): Generic: You pay $0 Preferred Brand: You pay $35 Non-Preferred Brand: You pay $45 Retail (per 90-day supply): Generic: You pay $0 Preferred Brand: You pay $105 Non-Preferred Brand: You pay $135 |
OAP HDHPQ Plan - OAP Base | |
---|---|
In-Network | Retail: You pay 0% Your plan pays 100% |
Open Access Plus Plan - OAP Buy Up | |
---|---|
In-Network | Home Delivery (per 90-day supply): Generic: You pay $0 Preferred Brand: You pay $90 Non-Preferred Brand: You pay $120 |
Out-of-Network | Home Delivery: Not Covered |
Open Access Plus Plan - OAP Mid | |
---|---|
In-Network | Home Delivery (per 90-day supply): Generic: You pay $0 Preferred Brand: You pay $105 Non-Preferred Brand: You pay $135 |
OAP HDHPQ Plan - OAP Base | |
---|---|
In-Network | Home Delivery: You pay 0% Your plan pays 100% |
All plans have exclusions and limitations. For a summary of these exclusions and limitations, view the Summary of Benefits and Coverage.