Your Medical Benefits
Open Access Plus Plan - OAP Buy Up
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.
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Plan Documents
| In-Network | Out-of-Network | |
|---|---|---|
| Plan Name | Open Access Plus Plan - OAP Buy Up | |
| Plan Coinsurance | Plan pays 70% | Plan pays 50% |
| Individual Deductible | Individual: $1,000 | Individual: $5,000 |
| Family Deductible | Family: $2,000 | Family: $10,000 |
| Individual Out-of-Pocket | Individual: $6,000 | Individual: $10,000 |
| Family Out-of-Pocket | Family: $12,000 | Family: $20,000 |
| Primary Care Office Visit | $25 copay, and plan pays 100% | Plan pays 50% |
| Specialist Care Office Visit | $50 copay, and plan pays 100% | Plan pays 50% |
| Emergency Room | $750 copay, and plan pays 70% | |
| Urgent Care | $100 copay, and plan pays 100% | Plan pays 50% |
| Outpatient Radiology | Plan pays 70% | Plan pays 50% |
| Independent Laboratory | Plan pays 70% | Plan pays 50% |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | $50 copay, and plan pays 100% | Plan pays 50% |
| Pharmacy Formulary | Advantage | |
| Retail Pharmacy Customer Share | Retail (per 30-day supply): Generic: You pay $20 Preferred Brand: You pay $60 Non-Preferred Brand: You pay $100 Specialty: You pay $150 Retail (per 90-day supply): Generic: You pay $60 Preferred Brand: You pay $180 Non-Preferred Brand: You pay $300 | Retail: You pay 50% Your plan pays 50% |
| Home Delivery Pharmacy Customer Share | Home Delivery (per 90-day supply): Generic: You pay $60 Preferred Brand: You pay $180 Non-Preferred Brand: You pay $300 Specialty: You pay $450 | 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.
| In-Network | Out-of-Network | |
|---|---|---|
| Plan Name | Open Access Plus Plan - OAP Buy Up | |
| Plan Coinsurance | Plan pays 70% | Plan pays 50% |
| Individual Deductible | Individual: $1,000 | Individual: $5,000 |
| Family Deductible | Family: $2,000 | Family: $10,000 |
| Individual Out-of-Pocket | Individual: $6,000 | Individual: $10,000 |
| Family Out-of-Pocket | Family: $12,000 | Family: $20,000 |
| Primary Care Office Visit | $25 copay, and plan pays 100% | Plan pays 50% |
| Specialist Care Office Visit | $50 copay, and plan pays 100% | Plan pays 50% |
| Emergency Room | $750 copay, and plan pays 70% | |
| Urgent Care | $100 copay, and plan pays 100% | Plan pays 50% |
| Outpatient Radiology | Plan pays 70% | Plan pays 50% |
| Independent Laboratory | Plan pays 70% | Plan pays 50% |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | $50 copay, and plan pays 100% | Plan pays 50% |
| Pharmacy Formulary | Advantage | |
| Retail Pharmacy Customer Share | Retail (per 30-day supply): Generic: You pay $20 Preferred Brand: You pay $60 Non-Preferred Brand: You pay $100 Specialty: You pay $150 Retail (per 90-day supply): Generic: You pay $60 Preferred Brand: You pay $180 Non-Preferred Brand: You pay $300 | Retail: You pay 50% Your plan pays 50% |
| Home Delivery Pharmacy Customer Share | Home Delivery (per 90-day supply): Generic: You pay $60 Preferred Brand: You pay $180 Non-Preferred Brand: You pay $300 Specialty: You pay $450 | 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.