Your Medical Benefits
Medical
Group # 00623380
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 Low | Open Access Plus Plan - OAP Mid | Open Access Plus Plan - OAP High | |
|---|---|---|---|
| Plan Coinsurance | |||
| In-Network | Plan pays 70% | Plan pays 70% | Plan pays 80% |
| Out-Of-Network | Plan pays 40% | Plan pays 50% | Plan pays 50% |
| Individual Deductible | |||
| In-Network | Individual: $8,500 | Individual: $5,600 | Individual: $2,000 |
| Out-Of-Network | Individual: $10,000 | Individual: $10,000 | Individual: $4,000 |
| Family Deductible | |||
| In-Network | Family: $17,000 | Family: $11,200 | Family: $4,000 |
| Out-Of-Network | Family: $20,000 | Family: $20,000 | Family: $8,000 |
| Individual Out-of-Pocket | |||
| In-Network | Individual: $9,100 | Individual: $7,150 | Individual: $7,150 |
| Out-Of-Network | Individual: $18,200 | Individual: $20,000 | Individual: $10,000 |
| Family Out-of-Pocket | |||
| In-Network | Family: $18,200 | Family: $14,300 | Family: $14,300 |
| Out-Of-Network | Family: $36,400 | Family: $40,000 | Family: $20,000 |
| Primary Care Office Visit | |||
| In-Network | $35 copay, and plan pays 100% | $30 copay, and plan pays 100% | $25 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 40% | Plan pays 50% | Plan pays 50% |
| Specialist Care Office Visit | |||
| In-Network | Plan pays 70% | $60 copay, and plan pays 100% | $50 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 40% | Plan pays 50% | Plan pays 50% |
| Emergency Room | |||
| $500 copay, and plan pays 70% | Plan pays 70% | Plan pays 80% | |
| Urgent Care | |||
| In-Network | $70 copay, and plan pays 100% | $60 copay, and plan pays 100% | $50 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 40% | Plan pays 50% | Plan pays 50% |
| Outpatient Radiology | |||
| In-Network | Plan pays 70% | Plan pays 70% | Plan pays 80% |
| Out-Of-Network | Plan pays 40% | Plan pays 50% | Plan pays 50% |
| Independent Laboratory | |||
| In-Network | Plan pays 100% | Plan pays 100% | Plan pays 100% |
| Out-Of-Network | Plan pays 40% | Plan pays 50% | Plan pays 50% |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | |||
| In-Network | Plan pays 70% | Plan pays 70% | Plan pays 80% |
| Out-Of-Network | Plan pays 40% | 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 $20 Preferred Brand: You pay $45 Non-Preferred Brand: You pay $100 | Retail (per 30-day supply): Generic: You pay $20 Preferred Brand: You pay $40 Non-Preferred Brand: You pay $70 | Retail (per 30-day supply): Generic: You pay $15 Preferred Brand: You pay $40 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 30-day supply): Specialty: You pay 30% up to a maximum of $300 Retail and Home Delivery (per 90-day supply): Generic: You pay $50 Preferred Brand: You pay $113 Non-Preferred Brand: You pay $250 | Retail and Home Delivery (per 30-day supply): Specialty: You pay $125 Retail and Home Delivery (per 90-day supply): Generic: You pay $50 Preferred Brand: You pay $100 Non-Preferred Brand: You pay $175 | Retail and Home Delivery (per 30-day supply): Specialty: You pay $125 Retail and Home Delivery (per 90-day supply): Generic: You pay $38 Preferred Brand: You pay $100 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 Low | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 40% |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP High | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 50% |
Individual Deductible
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Individual: $8,500 |
| Out-of-Network | Individual: $10,000 |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Individual: $5,600 |
| Out-of-Network | Individual: $10,000 |
| Open Access Plus Plan - OAP High | |
|---|---|
| In-Network | Individual: $2,000 |
| Out-of-Network | Individual: $4,000 |
Family Deductible
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Family: $17,000 |
| Out-of-Network | Family: $20,000 |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Family: $11,200 |
| Out-of-Network | Family: $20,000 |
| Open Access Plus Plan - OAP High | |
|---|---|
| In-Network | Family: $4,000 |
| Out-of-Network | Family: $8,000 |
Individual Out-of-Pocket
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Individual: $9,100 |
| Out-of-Network | Individual: $18,200 |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Individual: $7,150 |
| Out-of-Network | Individual: $20,000 |
| Open Access Plus Plan - OAP High | |
|---|---|
| In-Network | Individual: $7,150 |
| Out-of-Network | Individual: $10,000 |
Family Out-of-Pocket
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Family: $18,200 |
| Out-of-Network | Family: $36,400 |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Family: $14,300 |
| Out-of-Network | Family: $40,000 |
| Open Access Plus Plan - OAP High | |
|---|---|
| In-Network | Family: $14,300 |
| Out-of-Network | Family: $20,000 |
Primary Care Office Visit
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | $35 copay, and plan pays 100% |
| Out-of-Network | Plan pays 40% |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP High | |
|---|---|
| In-Network | $25 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
Specialist Care Office Visit
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 40% |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | $60 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP High | |
|---|---|
| In-Network | $50 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
Emergency Room
| Open Access Plus Plan - OAP Low | |
|---|---|
| $500 copay, and plan pays 70% |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| Plan pays 70% |
| Open Access Plus Plan - OAP High | |
|---|---|
| Plan pays 80% |
Urgent Care
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | $70 copay, and plan pays 100% |
| Out-of-Network | Plan pays 40% |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | $60 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP High | |
|---|---|
| In-Network | $50 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
Outpatient Radiology
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 40% |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP High | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 50% |
Independent Laboratory
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 40% |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP High | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 50% |
Outpatient Physical, Speech, Hearing, and Occupational Therapy
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 40% |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP High | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 50% |
Pharmacy Formulary
| Open Access Plus Plan - OAP Low | |
|---|---|
| Advantage |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| Advantage |
| Open Access Plus Plan - OAP High | |
|---|---|
| Advantage |
Retail Pharmacy Customer Share
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $20 Preferred Brand: You pay $45 Non-Preferred Brand: You pay $100 |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $20 Preferred Brand: You pay $40 Non-Preferred Brand: You pay $70 |
| Open Access Plus Plan - OAP High | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $15 Preferred Brand: You pay $40 Non-Preferred Brand: You pay $70 |
Home Delivery Pharmacy Customer Share
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay 30% up to a maximum of $300 Retail and Home Delivery (per 90-day supply): Generic: You pay $50 Preferred Brand: You pay $113 Non-Preferred Brand: You pay $250 |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay $125 Retail and Home Delivery (per 90-day supply): Generic: You pay $50 Preferred Brand: You pay $100 Non-Preferred Brand: You pay $175 |
| Open Access Plus Plan - OAP High | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay $125 Retail and Home Delivery (per 90-day supply): Generic: You pay $38 Preferred Brand: You pay $100 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 # 00623380
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 Low | Open Access Plus Plan - OAP Mid | Open Access Plus Plan - OAP High | |
|---|---|---|---|
| Plan Coinsurance | |||
| In-Network | Plan pays 70% | Plan pays 70% | Plan pays 80% |
| Out-Of-Network | Plan pays 40% | Plan pays 50% | Plan pays 50% |
| Individual Deductible | |||
| In-Network | Individual: $8,500 | Individual: $5,600 | Individual: $2,000 |
| Out-Of-Network | Individual: $10,000 | Individual: $10,000 | Individual: $4,000 |
| Family Deductible | |||
| In-Network | Family: $17,000 | Family: $11,200 | Family: $4,000 |
| Out-Of-Network | Family: $20,000 | Family: $20,000 | Family: $8,000 |
| Individual Out-of-Pocket | |||
| In-Network | Individual: $9,100 | Individual: $7,150 | Individual: $7,150 |
| Out-Of-Network | Individual: $18,200 | Individual: $20,000 | Individual: $10,000 |
| Family Out-of-Pocket | |||
| In-Network | Family: $18,200 | Family: $14,300 | Family: $14,300 |
| Out-Of-Network | Family: $36,400 | Family: $40,000 | Family: $20,000 |
| Primary Care Office Visit | |||
| In-Network | $35 copay, and plan pays 100% | $30 copay, and plan pays 100% | $25 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 40% | Plan pays 50% | Plan pays 50% |
| Specialist Care Office Visit | |||
| In-Network | Plan pays 70% | $60 copay, and plan pays 100% | $50 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 40% | Plan pays 50% | Plan pays 50% |
| Emergency Room | |||
| $500 copay, and plan pays 70% | Plan pays 70% | Plan pays 80% | |
| Urgent Care | |||
| In-Network | $70 copay, and plan pays 100% | $60 copay, and plan pays 100% | $50 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 40% | Plan pays 50% | Plan pays 50% |
| Outpatient Radiology | |||
| In-Network | Plan pays 70% | Plan pays 70% | Plan pays 80% |
| Out-Of-Network | Plan pays 40% | Plan pays 50% | Plan pays 50% |
| Independent Laboratory | |||
| In-Network | Plan pays 100% | Plan pays 100% | Plan pays 100% |
| Out-Of-Network | Plan pays 40% | Plan pays 50% | Plan pays 50% |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | |||
| In-Network | Plan pays 70% | Plan pays 70% | Plan pays 80% |
| Out-Of-Network | Plan pays 40% | 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 $20 Preferred Brand: You pay $45 Non-Preferred Brand: You pay $100 | Retail (per 30-day supply): Generic: You pay $20 Preferred Brand: You pay $40 Non-Preferred Brand: You pay $70 | Retail (per 30-day supply): Generic: You pay $15 Preferred Brand: You pay $40 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 30-day supply): Specialty: You pay 30% up to a maximum of $300 Retail and Home Delivery (per 90-day supply): Generic: You pay $50 Preferred Brand: You pay $113 Non-Preferred Brand: You pay $250 | Retail and Home Delivery (per 30-day supply): Specialty: You pay $125 Retail and Home Delivery (per 90-day supply): Generic: You pay $50 Preferred Brand: You pay $100 Non-Preferred Brand: You pay $175 | Retail and Home Delivery (per 30-day supply): Specialty: You pay $125 Retail and Home Delivery (per 90-day supply): Generic: You pay $38 Preferred Brand: You pay $100 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 Low | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 40% |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP High | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 50% |
Individual Deductible
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Individual: $8,500 |
| Out-of-Network | Individual: $10,000 |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Individual: $5,600 |
| Out-of-Network | Individual: $10,000 |
| Open Access Plus Plan - OAP High | |
|---|---|
| In-Network | Individual: $2,000 |
| Out-of-Network | Individual: $4,000 |
Family Deductible
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Family: $17,000 |
| Out-of-Network | Family: $20,000 |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Family: $11,200 |
| Out-of-Network | Family: $20,000 |
| Open Access Plus Plan - OAP High | |
|---|---|
| In-Network | Family: $4,000 |
| Out-of-Network | Family: $8,000 |
Individual Out-of-Pocket
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Individual: $9,100 |
| Out-of-Network | Individual: $18,200 |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Individual: $7,150 |
| Out-of-Network | Individual: $20,000 |
| Open Access Plus Plan - OAP High | |
|---|---|
| In-Network | Individual: $7,150 |
| Out-of-Network | Individual: $10,000 |
Family Out-of-Pocket
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Family: $18,200 |
| Out-of-Network | Family: $36,400 |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Family: $14,300 |
| Out-of-Network | Family: $40,000 |
| Open Access Plus Plan - OAP High | |
|---|---|
| In-Network | Family: $14,300 |
| Out-of-Network | Family: $20,000 |
Primary Care Office Visit
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | $35 copay, and plan pays 100% |
| Out-of-Network | Plan pays 40% |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP High | |
|---|---|
| In-Network | $25 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
Specialist Care Office Visit
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 40% |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | $60 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP High | |
|---|---|
| In-Network | $50 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
Emergency Room
| Open Access Plus Plan - OAP Low | |
|---|---|
| $500 copay, and plan pays 70% |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| Plan pays 70% |
| Open Access Plus Plan - OAP High | |
|---|---|
| Plan pays 80% |
Urgent Care
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | $70 copay, and plan pays 100% |
| Out-of-Network | Plan pays 40% |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | $60 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP High | |
|---|---|
| In-Network | $50 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
Outpatient Radiology
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 40% |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP High | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 50% |
Independent Laboratory
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 40% |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP High | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 50% |
Outpatient Physical, Speech, Hearing, and Occupational Therapy
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 40% |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP High | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 50% |
Pharmacy Formulary
| Open Access Plus Plan - OAP Low | |
|---|---|
| Advantage |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| Advantage |
| Open Access Plus Plan - OAP High | |
|---|---|
| Advantage |
Retail Pharmacy Customer Share
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $20 Preferred Brand: You pay $45 Non-Preferred Brand: You pay $100 |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $20 Preferred Brand: You pay $40 Non-Preferred Brand: You pay $70 |
| Open Access Plus Plan - OAP High | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $15 Preferred Brand: You pay $40 Non-Preferred Brand: You pay $70 |
Home Delivery Pharmacy Customer Share
| Open Access Plus Plan - OAP Low | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay 30% up to a maximum of $300 Retail and Home Delivery (per 90-day supply): Generic: You pay $50 Preferred Brand: You pay $113 Non-Preferred Brand: You pay $250 |
| Open Access Plus Plan - OAP Mid | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay $125 Retail and Home Delivery (per 90-day supply): Generic: You pay $50 Preferred Brand: You pay $100 Non-Preferred Brand: You pay $175 |
| Open Access Plus Plan - OAP High | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay $125 Retail and Home Delivery (per 90-day supply): Generic: You pay $38 Preferred Brand: You pay $100 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.