Your Medical Benefits
Open Access Plus Plan - OAP Low
Benefit Summary
Group # 00623380
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.
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Plan Documents
| In-Network | Out-of-Network | |
|---|---|---|
| Plan Name | Open Access Plus Plan - OAP Low | |
| Plan Coinsurance | Plan pays 70% | Plan pays 40% |
| Individual Deductible | Individual: $8,500 | Individual: $10,000 |
| Family Deductible | Family: $17,000 | Family: $20,000 |
| Individual Out-of-Pocket | Individual: $9,100 | Individual: $18,200 |
| Family Out-of-Pocket | Family: $18,200 | Family: $36,400 |
| Primary Care Office Visit | $35 copay, and plan pays 100% | Plan pays 40% |
| Specialist Care Office Visit | Plan pays 70% | Plan pays 40% |
| Emergency Room | $500 copay, and plan pays 70% | |
| Urgent Care | $70 copay, and plan pays 100% | Plan pays 40% |
| Outpatient Radiology | Plan pays 70% | Plan pays 40% |
| Independent Laboratory | Plan pays 100% | Plan pays 40% |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | Plan pays 70% | Plan pays 40% |
| Pharmacy Formulary | Advantage | |
| Retail Pharmacy Customer Share | Retail (per 30-day supply): Generic: You pay $20 Preferred Brand: You pay $45 Non-Preferred Brand: You pay $100 | Not Covered for all benefits |
| Home Delivery Pharmacy Customer Share | 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 | 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 # 00623380
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 Low | |
| Plan Coinsurance | Plan pays 70% | Plan pays 40% |
| Individual Deductible | Individual: $8,500 | Individual: $10,000 |
| Family Deductible | Family: $17,000 | Family: $20,000 |
| Individual Out-of-Pocket | Individual: $9,100 | Individual: $18,200 |
| Family Out-of-Pocket | Family: $18,200 | Family: $36,400 |
| Primary Care Office Visit | $35 copay, and plan pays 100% | Plan pays 40% |
| Specialist Care Office Visit | Plan pays 70% | Plan pays 40% |
| Emergency Room | $500 copay, and plan pays 70% | |
| Urgent Care | $70 copay, and plan pays 100% | Plan pays 40% |
| Outpatient Radiology | Plan pays 70% | Plan pays 40% |
| Independent Laboratory | Plan pays 100% | Plan pays 40% |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | Plan pays 70% | Plan pays 40% |
| Pharmacy Formulary | Advantage | |
| Retail Pharmacy Customer Share | Retail (per 30-day supply): Generic: You pay $20 Preferred Brand: You pay $45 Non-Preferred Brand: You pay $100 | Not Covered for all benefits |
| Home Delivery Pharmacy Customer Share | 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 | 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.