Your Medical Benefits
Open Access Plus Plan - OAP Mid
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 Mid | |
Plan Coinsurance | Plan pays 80% | Plan pays 60% |
Individual Deductible | Individual: $3,000 | Individual: $6,000 |
Family Deductible | Family: $6,000 | Family: $12,000 |
Individual Out-of-Pocket | Individual: $6,000 | Individual: $12,000 |
Family Out-of-Pocket | Family: $12,000 | Family: $24,000 |
Primary Care Office Visit | $40 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 | $75 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 $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 | Not Covered for all benefits |
Home Delivery Pharmacy Customer Share | Home Delivery (per 90-day supply): Generic: You pay $0 Preferred Brand: You pay $105 Non-Preferred Brand: You pay $135 | Not Covered for all benefits |
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 Mid | |
Plan Coinsurance | Plan pays 80% | Plan pays 60% |
Individual Deductible | Individual: $3,000 | Individual: $6,000 |
Family Deductible | Family: $6,000 | Family: $12,000 |
Individual Out-of-Pocket | Individual: $6,000 | Individual: $12,000 |
Family Out-of-Pocket | Family: $12,000 | Family: $24,000 |
Primary Care Office Visit | $40 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 | $75 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 $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 | Not Covered for all benefits |
Home Delivery Pharmacy Customer Share | Home Delivery (per 90-day supply): Generic: You pay $0 Preferred Brand: You pay $105 Non-Preferred Brand: You pay $135 | Not Covered for all benefits |
All plans have exclusions and limitations. For a summary of these exclusions and limitations, view the Summary of Benefits and Coverage.