Your Medical Benefits
OAP HDHPQ Plan - HDHPQ OAP BuyUp
Benefit Summary
Group # 00650877
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.
A HDHP, or High Deductible Health Plan, can be combined with a tax-advantaged saving account allowing you to pay for certain medical expenses with money free from federal taxes. Until you reach your deductible, you must pay for most of your health care expenses out-of-pocket.
Note: The Plan deductible always applies before any benefit copay/deductible or coinsurance.
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Plan Documents
| In-Network | Out-of-Network | |
|---|---|---|
| Plan Name | OAP HDHPQ Plan - HDHPQ OAP BuyUp | |
| Plan Coinsurance | Plan pays 90% | Plan pays 50% |
| Individual Deductible | Individual - Employee Only: $5,000 Individual - within a Family: $5,000 | Individual - Employee Only: $10,000 Individual - within a Family: $10,000 |
| Family Deductible | Family Maximum: $10,000 | Family Maximum: $20,000 |
| Individual Out-of-Pocket | Individual - Employee Only: $8,500 Individual - within a Family: $8,500 | Individual - Employee Only: $20,000 Individual - within a Family: $20,000 |
| Family Out-of-Pocket | Family Maximum: $17,000 | Family Maximum: $40,000 |
| Primary Care Office Visit | Plan pays 90% | Plan pays 50% |
| Specialist Care Office Visit | Plan pays 90% | Plan pays 50% |
| Emergency Room | Plan pays 90% | |
| Urgent Care | Plan pays 90% | Plan pays 50% |
| Outpatient Radiology | Plan pays 90% | Plan pays 50% |
| Independent Laboratory | Plan pays 90% | Plan pays 50% |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | Plan pays 90% | Plan pays 50% |
| Pharmacy Formulary | Advantage | |
| Retail Pharmacy Customer Share | Retail (per 30-day supply): Generic: You pay $30 Preferred Brand: You pay $80 Non-Preferred Brand: You pay $160 Specialty: You pay 30% up to a maximum of $350 Retail (per 90-day supply): Generic: You pay $75 Preferred Brand: You pay $200 Non-Preferred Brand: You pay $400 | Retail: You pay 50% Your plan pays 50% |
| Home Delivery Pharmacy Customer Share | Home Delivery (per 90-day supply): Generic: You pay $90 Preferred Brand: You pay $240 Non-Preferred Brand: You pay $480 Specialty: You pay 30% up to a maximum of $480 | 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 # 00650877
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.
A HDHP, or High Deductible Health Plan, can be combined with a tax-advantaged saving account allowing you to pay for certain medical expenses with money free from federal taxes. Until you reach your deductible, you must pay for most of your health care expenses out-of-pocket.
Note: The Plan deductible always applies before any benefit copay/deductible or coinsurance.
| In-Network | Out-of-Network | |
|---|---|---|
| Plan Name | OAP HDHPQ Plan - HDHPQ OAP BuyUp | |
| Plan Coinsurance | Plan pays 90% | Plan pays 50% |
| Individual Deductible | Individual - Employee Only: $5,000 Individual - within a Family: $5,000 | Individual - Employee Only: $10,000 Individual - within a Family: $10,000 |
| Family Deductible | Family Maximum: $10,000 | Family Maximum: $20,000 |
| Individual Out-of-Pocket | Individual - Employee Only: $8,500 Individual - within a Family: $8,500 | Individual - Employee Only: $20,000 Individual - within a Family: $20,000 |
| Family Out-of-Pocket | Family Maximum: $17,000 | Family Maximum: $40,000 |
| Primary Care Office Visit | Plan pays 90% | Plan pays 50% |
| Specialist Care Office Visit | Plan pays 90% | Plan pays 50% |
| Emergency Room | Plan pays 90% | |
| Urgent Care | Plan pays 90% | Plan pays 50% |
| Outpatient Radiology | Plan pays 90% | Plan pays 50% |
| Independent Laboratory | Plan pays 90% | Plan pays 50% |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | Plan pays 90% | Plan pays 50% |
| Pharmacy Formulary | Advantage | |
| Retail Pharmacy Customer Share | Retail (per 30-day supply): Generic: You pay $30 Preferred Brand: You pay $80 Non-Preferred Brand: You pay $160 Specialty: You pay 30% up to a maximum of $350 Retail (per 90-day supply): Generic: You pay $75 Preferred Brand: You pay $200 Non-Preferred Brand: You pay $400 | Retail: You pay 50% Your plan pays 50% |
| Home Delivery Pharmacy Customer Share | Home Delivery (per 90-day supply): Generic: You pay $90 Preferred Brand: You pay $240 Non-Preferred Brand: You pay $480 Specialty: You pay 30% up to a maximum of $480 | 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.