Your Medical Benefits
Open Access Plus Plan - OAP Buy Up
Benefit Summary
Group # 00635670
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 Buy Up | |
Plan Coinsurance | Plan pays 80% | Plan pays 60% |
Individual Deductible | Individual: $2,000 | Individual: $5,000 |
Family Deductible | Family: $4,000 | Family: $15,000 |
Individual Out-of-Pocket | Individual: $5,000 | Individual: $11,000 |
Family Out-of-Pocket | Family: $10,000 | Family: $33,000 |
Primary Care Office Visit | $30 copay, and plan pays 100% | Plan pays 60% |
Specialist Care Office Visit | $75 copay, and plan pays 100% | Plan pays 60% |
Emergency Room | $500 copay, and plan pays 80% | |
Urgent Care | $60 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 | $75 copay, and plan pays 100% | Plan pays 60% |
Pharmacy Formulary | Advantage | |
Retail Pharmacy Customer Share | 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: You pay 60% Your plan pays 40% |
Home Delivery Pharmacy Customer Share | Home Delivery (per 90-day supply): Generic: You pay $0 Preferred Brand: You pay $90 Non-Preferred Brand: You pay $120 | 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 # 00635670
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 Buy Up | |
Plan Coinsurance | Plan pays 80% | Plan pays 60% |
Individual Deductible | Individual: $2,000 | Individual: $5,000 |
Family Deductible | Family: $4,000 | Family: $15,000 |
Individual Out-of-Pocket | Individual: $5,000 | Individual: $11,000 |
Family Out-of-Pocket | Family: $10,000 | Family: $33,000 |
Primary Care Office Visit | $30 copay, and plan pays 100% | Plan pays 60% |
Specialist Care Office Visit | $75 copay, and plan pays 100% | Plan pays 60% |
Emergency Room | $500 copay, and plan pays 80% | |
Urgent Care | $60 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 | $75 copay, and plan pays 100% | Plan pays 60% |
Pharmacy Formulary | Advantage | |
Retail Pharmacy Customer Share | 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: You pay 60% Your plan pays 40% |
Home Delivery Pharmacy Customer Share | Home Delivery (per 90-day supply): Generic: You pay $0 Preferred Brand: You pay $90 Non-Preferred Brand: You pay $120 | 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.