Your Medical Benefits
Medical
Group # 3346200
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 - OAP | HMO - Select HMO | HMO - Full HMO | Open Access Plus - HDHPQ OAP | |
|---|---|---|---|---|
| Plan Coinsurance | ||||
| In-Network | Plan pays 80% | Plan pays 100% | Plan pays 100% | Plan pays 80% |
| Out-Of-Network | Plan pays 60% | Not Covered for all benefits | Not Covered for all benefits | Plan pays 60% |
| Plan Deductible (Individual) | ||||
| In-Network | Individual: $1,500 | Individual: None | Individual: None | Individual - Employee Only: $3,000 Individual - within a Family: $3,400 |
| Out-Of-Network | Individual: $2,000 | Not Covered for all benefits | Not Covered for all benefits | Individual - Employee Only: $5,000 Individual - within a Family: $6,800 |
| Plan Deductible (Family) | ||||
| In-Network | Family: $3,000 | Family: None | Family: None | Family Maximum: $6,000 |
| Out-Of-Network | Family: $4,000 | Not Covered for all benefits | Not Covered for all benefits | Family Maximum: $10,000 |
| Plan Out-of-Pocket (Individual) | ||||
| In-Network | Individual: $3,000 | Individual: $2,000 | Individual: $2,000 | Individual - Employee Only: $4,500 Individual - within a Family: $4,500 |
| Out-Of-Network | Individual: $6,000 | Not Covered for all benefits | Not Covered for all benefits | Individual - Employee Only: $8,000 Individual - within a Family: $8,000 |
| Plan Out-of-Pocket (Family) | ||||
| In-Network | Family: $6,000 | Family: $4,000 | Family: $4,000 | Family Maximum: $8,000 |
| Out-Of-Network | Family: $12,000 | Not Covered for all benefits | Not Covered for all benefits | Family Maximum: $14,500 |
| Primary Care Physician Office Visit | ||||
| In-Network | $30 copay, and plan pays 100% | $30 copay, and plan pays 100% | $30 copay, and plan pays 100% | $30 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 60% | Not Covered for all benefits | Not Covered for all benefits | Plan pays 60% |
| Specialist Care Physician Office Visit | ||||
| In-Network | $50 copay, and plan pays 100% | $50 copay, and plan pays 100% | $50 copay, and plan pays 100% | $50 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 60% | Not Covered for all benefits | Not Covered for all benefits | Plan pays 60% |
| Emergency Room | ||||
| Plan pays 80% | $200 copay, and plan pays 100% | $200 copay, and plan pays 100% | Plan pays 80% | |
| Urgent Care | ||||
| In-Network | $25 copay, and plan pays 100% | $30 copay, and plan pays 100% | $30 copay, and plan pays 100% | $25 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 60% | Not Covered for all benefits | Not Covered for all benefits | Plan pays 60% |
| Outpatient Radiology | ||||
| In-Network | Plan pays 80% | Plan pays 100% | Plan pays 100% | Plan pays 80% |
| Out-Of-Network | Plan pays 60% | Not Covered for all benefits | Not Covered for all benefits | Plan pays 60% |
| Independent Laboratory | ||||
| In-Network | Plan pays 80% | Plan pays 100% | Plan pays 100% | Plan pays 80% |
| Out-Of-Network | Plan pays 60% | Not Covered for all benefits | Not Covered for all benefits | Plan pays 60% |
| Formulary Type | ||||
| Standard | Standard | Standard | Standard | |
| Retail Pharmacy | ||||
| In-Network | Retail (per 30-day supply): Generic: You pay $25 Preferred Brand: You pay $40 Non-Preferred Brand: You pay $60 | Retail (per 30-day supply): Generic: You pay $15 Preferred Brand: You pay $40 Non-Preferred Brand: You pay $60 | Retail (per 30-day supply): Generic: You pay $15 Preferred Brand: You pay $40 Non-Preferred Brand: You pay $60 | Retail (per 30-day supply): Generic: You pay $25 Preferred Brand: You pay $40 Non-Preferred Brand: You pay $60 |
| Out-Of-Network | Not Covered for all benefits | Not Covered for all benefits | Not Covered for all benefits | Not Covered for all benefits |
| Home Delivery Pharmacy | ||||
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay $100 Retail and Home Delivery (per 90-day supply): Generic: You pay $50 Preferred Brand: You pay $80 Non-Preferred Brand: You pay $120 | Retail and Home Delivery (per 30-day supply): Specialty: You pay $100 Retail and Home Delivery (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $80 Non-Preferred Brand: You pay $120 | Retail and Home Delivery (per 30-day supply): Specialty: You pay $100 Retail and Home Delivery (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $80 Non-Preferred Brand: You pay $120 | Retail and Home Delivery (per 30-day supply): Specialty: You pay $100 Retail and Home Delivery (per 90-day supply): Generic: You pay $50 Preferred Brand: You pay $80 Non-Preferred Brand: You pay $120 |
| Out-Of-Network | Not Covered for all benefits | Not Covered for all benefits | Not Covered for all benefits | Not Covered for all benefits |
| Outpatient Therapy and Chiropractic Services | ||||
| In-Network | Not Covered for all benefits | Not Covered for all benefits | Not Covered for all benefits | Covered same as Physician Services - Office Visit |
| Out-Of-Network | Not Covered for all benefits | Not Covered for all benefits | Not Covered for all benefits | Covered same as Physician Services - Office Visit |
Plan Coinsurance
| Open Access Plus - OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| HMO - Select HMO | |
|---|---|
| In-Network | Plan pays 100% |
| HMO - Full HMO | |
|---|---|
| In-Network | Plan pays 100% |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
Plan Deductible (Individual)
| Open Access Plus - OAP | |
|---|---|
| In-Network | Individual: $1,500 |
| Out-of-Network | Individual: $2,000 |
| HMO - Select HMO | |
|---|---|
| In-Network | Individual: None |
| HMO - Full HMO | |
|---|---|
| In-Network | Individual: None |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Individual - Employee Only: $3,000 Individual - within a Family: $3,400 |
| Out-of-Network | Individual - Employee Only: $5,000 Individual - within a Family: $6,800 |
Plan Deductible (Family)
| Open Access Plus - OAP | |
|---|---|
| In-Network | Family: $3,000 |
| Out-of-Network | Family: $4,000 |
| HMO - Select HMO | |
|---|---|
| In-Network | Family: None |
| HMO - Full HMO | |
|---|---|
| In-Network | Family: None |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Family Maximum: $6,000 |
| Out-of-Network | Family Maximum: $10,000 |
Plan Out-of-Pocket (Individual)
| Open Access Plus - OAP | |
|---|---|
| In-Network | Individual: $3,000 |
| Out-of-Network | Individual: $6,000 |
| HMO - Select HMO | |
|---|---|
| In-Network | Individual: $2,000 |
| HMO - Full HMO | |
|---|---|
| In-Network | Individual: $2,000 |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Individual - Employee Only: $4,500 Individual - within a Family: $4,500 |
| Out-of-Network | Individual - Employee Only: $8,000 Individual - within a Family: $8,000 |
Plan Out-of-Pocket (Family)
| Open Access Plus - OAP | |
|---|---|
| In-Network | Family: $6,000 |
| Out-of-Network | Family: $12,000 |
| HMO - Select HMO | |
|---|---|
| In-Network | Family: $4,000 |
| HMO - Full HMO | |
|---|---|
| In-Network | Family: $4,000 |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Family Maximum: $8,000 |
| Out-of-Network | Family Maximum: $14,500 |
Primary Care Physician Office Visit
| Open Access Plus - OAP | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| HMO - Select HMO | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| HMO - Full HMO | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
Specialist Care Physician Office Visit
| Open Access Plus - OAP | |
|---|---|
| In-Network | $50 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| HMO - Select HMO | |
|---|---|
| In-Network | $50 copay, and plan pays 100% |
| HMO - Full HMO | |
|---|---|
| In-Network | $50 copay, and plan pays 100% |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | $50 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
Emergency Room
| Open Access Plus - OAP | |
|---|---|
| Plan pays 80% |
| HMO - Select HMO | |
|---|---|
| $200 copay, and plan pays 100% |
| HMO - Full HMO | |
|---|---|
| $200 copay, and plan pays 100% |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| Plan pays 80% |
Urgent Care
| Open Access Plus - OAP | |
|---|---|
| In-Network | $25 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| HMO - Select HMO | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| HMO - Full HMO | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | $25 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
Outpatient Radiology
| Open Access Plus - OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| HMO - Select HMO | |
|---|---|
| In-Network | Plan pays 100% |
| HMO - Full HMO | |
|---|---|
| In-Network | Plan pays 100% |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
Independent Laboratory
| Open Access Plus - OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| HMO - Select HMO | |
|---|---|
| In-Network | Plan pays 100% |
| HMO - Full HMO | |
|---|---|
| In-Network | Plan pays 100% |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
Formulary Type
| Open Access Plus - OAP | |
|---|---|
| Standard |
| HMO - Select HMO | |
|---|---|
| Standard |
| HMO - Full HMO | |
|---|---|
| Standard |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| Standard |
Retail Pharmacy
| Open Access Plus - OAP | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $25 Preferred Brand: You pay $40 Non-Preferred Brand: You pay $60 |
| HMO - Select HMO | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $15 Preferred Brand: You pay $40 Non-Preferred Brand: You pay $60 |
| HMO - Full HMO | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $15 Preferred Brand: You pay $40 Non-Preferred Brand: You pay $60 |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $25 Preferred Brand: You pay $40 Non-Preferred Brand: You pay $60 |
Home Delivery Pharmacy
| Open Access Plus - OAP | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay $100 Retail and Home Delivery (per 90-day supply): Generic: You pay $50 Preferred Brand: You pay $80 Non-Preferred Brand: You pay $120 |
| HMO - Select HMO | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay $100 Retail and Home Delivery (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $80 Non-Preferred Brand: You pay $120 |
| HMO - Full HMO | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay $100 Retail and Home Delivery (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $80 Non-Preferred Brand: You pay $120 |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay $100 Retail and Home Delivery (per 90-day supply): Generic: You pay $50 Preferred Brand: You pay $80 Non-Preferred Brand: You pay $120 |
Outpatient Therapy and Chiropractic Services
| Open Access Plus - OAP | |
|---|---|
| HMO - Select HMO | |
|---|---|
| HMO - Full HMO | |
|---|---|
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Covered same as Physician Services - Office Visit |
| Out-of-Network | Covered same as Physician Services - Office Visit |
All plans have exclusions and limitations. For a summary of these exclusions and limitations, view the Summary of Benefits and Coverage.
Medical
Group # 3346200
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 - OAP | HMO - Select HMO | HMO - Full HMO | Open Access Plus - HDHPQ OAP | |
|---|---|---|---|---|
| Plan Coinsurance | ||||
| In-Network | Plan pays 80% | Plan pays 100% | Plan pays 100% | Plan pays 80% |
| Out-Of-Network | Plan pays 60% | Not Covered for all benefits | Not Covered for all benefits | Plan pays 60% |
| Plan Deductible (Individual) | ||||
| In-Network | Individual: $1,500 | Individual: None | Individual: None | Individual - Employee Only: $3,000 Individual - within a Family: $3,400 |
| Out-Of-Network | Individual: $2,000 | Not Covered for all benefits | Not Covered for all benefits | Individual - Employee Only: $5,000 Individual - within a Family: $6,800 |
| Plan Deductible (Family) | ||||
| In-Network | Family: $3,000 | Family: None | Family: None | Family Maximum: $6,000 |
| Out-Of-Network | Family: $4,000 | Not Covered for all benefits | Not Covered for all benefits | Family Maximum: $10,000 |
| Plan Out-of-Pocket (Individual) | ||||
| In-Network | Individual: $3,000 | Individual: $2,000 | Individual: $2,000 | Individual - Employee Only: $4,500 Individual - within a Family: $4,500 |
| Out-Of-Network | Individual: $6,000 | Not Covered for all benefits | Not Covered for all benefits | Individual - Employee Only: $8,000 Individual - within a Family: $8,000 |
| Plan Out-of-Pocket (Family) | ||||
| In-Network | Family: $6,000 | Family: $4,000 | Family: $4,000 | Family Maximum: $8,000 |
| Out-Of-Network | Family: $12,000 | Not Covered for all benefits | Not Covered for all benefits | Family Maximum: $14,500 |
| Primary Care Physician Office Visit | ||||
| In-Network | $30 copay, and plan pays 100% | $30 copay, and plan pays 100% | $30 copay, and plan pays 100% | $30 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 60% | Not Covered for all benefits | Not Covered for all benefits | Plan pays 60% |
| Specialist Care Physician Office Visit | ||||
| In-Network | $50 copay, and plan pays 100% | $50 copay, and plan pays 100% | $50 copay, and plan pays 100% | $50 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 60% | Not Covered for all benefits | Not Covered for all benefits | Plan pays 60% |
| Emergency Room | ||||
| Plan pays 80% | $200 copay, and plan pays 100% | $200 copay, and plan pays 100% | Plan pays 80% | |
| Urgent Care | ||||
| In-Network | $25 copay, and plan pays 100% | $30 copay, and plan pays 100% | $30 copay, and plan pays 100% | $25 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 60% | Not Covered for all benefits | Not Covered for all benefits | Plan pays 60% |
| Outpatient Radiology | ||||
| In-Network | Plan pays 80% | Plan pays 100% | Plan pays 100% | Plan pays 80% |
| Out-Of-Network | Plan pays 60% | Not Covered for all benefits | Not Covered for all benefits | Plan pays 60% |
| Independent Laboratory | ||||
| In-Network | Plan pays 80% | Plan pays 100% | Plan pays 100% | Plan pays 80% |
| Out-Of-Network | Plan pays 60% | Not Covered for all benefits | Not Covered for all benefits | Plan pays 60% |
| Formulary Type | ||||
| Standard | Standard | Standard | Standard | |
| Retail Pharmacy | ||||
| In-Network | Retail (per 30-day supply): Generic: You pay $25 Preferred Brand: You pay $40 Non-Preferred Brand: You pay $60 | Retail (per 30-day supply): Generic: You pay $15 Preferred Brand: You pay $40 Non-Preferred Brand: You pay $60 | Retail (per 30-day supply): Generic: You pay $15 Preferred Brand: You pay $40 Non-Preferred Brand: You pay $60 | Retail (per 30-day supply): Generic: You pay $25 Preferred Brand: You pay $40 Non-Preferred Brand: You pay $60 |
| Out-Of-Network | Not Covered for all benefits | Not Covered for all benefits | Not Covered for all benefits | Not Covered for all benefits |
| Home Delivery Pharmacy | ||||
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay $100 Retail and Home Delivery (per 90-day supply): Generic: You pay $50 Preferred Brand: You pay $80 Non-Preferred Brand: You pay $120 | Retail and Home Delivery (per 30-day supply): Specialty: You pay $100 Retail and Home Delivery (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $80 Non-Preferred Brand: You pay $120 | Retail and Home Delivery (per 30-day supply): Specialty: You pay $100 Retail and Home Delivery (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $80 Non-Preferred Brand: You pay $120 | Retail and Home Delivery (per 30-day supply): Specialty: You pay $100 Retail and Home Delivery (per 90-day supply): Generic: You pay $50 Preferred Brand: You pay $80 Non-Preferred Brand: You pay $120 |
| Out-Of-Network | Not Covered for all benefits | Not Covered for all benefits | Not Covered for all benefits | Not Covered for all benefits |
| Outpatient Therapy and Chiropractic Services | ||||
| In-Network | Not Covered for all benefits | Not Covered for all benefits | Not Covered for all benefits | Covered same as Physician Services - Office Visit |
| Out-Of-Network | Not Covered for all benefits | Not Covered for all benefits | Not Covered for all benefits | Covered same as Physician Services - Office Visit |
Plan Coinsurance
| Open Access Plus - OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| HMO - Select HMO | |
|---|---|
| In-Network | Plan pays 100% |
| HMO - Full HMO | |
|---|---|
| In-Network | Plan pays 100% |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
Plan Deductible (Individual)
| Open Access Plus - OAP | |
|---|---|
| In-Network | Individual: $1,500 |
| Out-of-Network | Individual: $2,000 |
| HMO - Select HMO | |
|---|---|
| In-Network | Individual: None |
| HMO - Full HMO | |
|---|---|
| In-Network | Individual: None |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Individual - Employee Only: $3,000 Individual - within a Family: $3,400 |
| Out-of-Network | Individual - Employee Only: $5,000 Individual - within a Family: $6,800 |
Plan Deductible (Family)
| Open Access Plus - OAP | |
|---|---|
| In-Network | Family: $3,000 |
| Out-of-Network | Family: $4,000 |
| HMO - Select HMO | |
|---|---|
| In-Network | Family: None |
| HMO - Full HMO | |
|---|---|
| In-Network | Family: None |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Family Maximum: $6,000 |
| Out-of-Network | Family Maximum: $10,000 |
Plan Out-of-Pocket (Individual)
| Open Access Plus - OAP | |
|---|---|
| In-Network | Individual: $3,000 |
| Out-of-Network | Individual: $6,000 |
| HMO - Select HMO | |
|---|---|
| In-Network | Individual: $2,000 |
| HMO - Full HMO | |
|---|---|
| In-Network | Individual: $2,000 |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Individual - Employee Only: $4,500 Individual - within a Family: $4,500 |
| Out-of-Network | Individual - Employee Only: $8,000 Individual - within a Family: $8,000 |
Plan Out-of-Pocket (Family)
| Open Access Plus - OAP | |
|---|---|
| In-Network | Family: $6,000 |
| Out-of-Network | Family: $12,000 |
| HMO - Select HMO | |
|---|---|
| In-Network | Family: $4,000 |
| HMO - Full HMO | |
|---|---|
| In-Network | Family: $4,000 |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Family Maximum: $8,000 |
| Out-of-Network | Family Maximum: $14,500 |
Primary Care Physician Office Visit
| Open Access Plus - OAP | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| HMO - Select HMO | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| HMO - Full HMO | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
Specialist Care Physician Office Visit
| Open Access Plus - OAP | |
|---|---|
| In-Network | $50 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| HMO - Select HMO | |
|---|---|
| In-Network | $50 copay, and plan pays 100% |
| HMO - Full HMO | |
|---|---|
| In-Network | $50 copay, and plan pays 100% |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | $50 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
Emergency Room
| Open Access Plus - OAP | |
|---|---|
| Plan pays 80% |
| HMO - Select HMO | |
|---|---|
| $200 copay, and plan pays 100% |
| HMO - Full HMO | |
|---|---|
| $200 copay, and plan pays 100% |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| Plan pays 80% |
Urgent Care
| Open Access Plus - OAP | |
|---|---|
| In-Network | $25 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| HMO - Select HMO | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| HMO - Full HMO | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | $25 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
Outpatient Radiology
| Open Access Plus - OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| HMO - Select HMO | |
|---|---|
| In-Network | Plan pays 100% |
| HMO - Full HMO | |
|---|---|
| In-Network | Plan pays 100% |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
Independent Laboratory
| Open Access Plus - OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| HMO - Select HMO | |
|---|---|
| In-Network | Plan pays 100% |
| HMO - Full HMO | |
|---|---|
| In-Network | Plan pays 100% |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
Formulary Type
| Open Access Plus - OAP | |
|---|---|
| Standard |
| HMO - Select HMO | |
|---|---|
| Standard |
| HMO - Full HMO | |
|---|---|
| Standard |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| Standard |
Retail Pharmacy
| Open Access Plus - OAP | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $25 Preferred Brand: You pay $40 Non-Preferred Brand: You pay $60 |
| HMO - Select HMO | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $15 Preferred Brand: You pay $40 Non-Preferred Brand: You pay $60 |
| HMO - Full HMO | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $15 Preferred Brand: You pay $40 Non-Preferred Brand: You pay $60 |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $25 Preferred Brand: You pay $40 Non-Preferred Brand: You pay $60 |
Home Delivery Pharmacy
| Open Access Plus - OAP | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay $100 Retail and Home Delivery (per 90-day supply): Generic: You pay $50 Preferred Brand: You pay $80 Non-Preferred Brand: You pay $120 |
| HMO - Select HMO | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay $100 Retail and Home Delivery (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $80 Non-Preferred Brand: You pay $120 |
| HMO - Full HMO | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay $100 Retail and Home Delivery (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $80 Non-Preferred Brand: You pay $120 |
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay $100 Retail and Home Delivery (per 90-day supply): Generic: You pay $50 Preferred Brand: You pay $80 Non-Preferred Brand: You pay $120 |
Outpatient Therapy and Chiropractic Services
| Open Access Plus - OAP | |
|---|---|
| HMO - Select HMO | |
|---|---|
| HMO - Full HMO | |
|---|---|
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Covered same as Physician Services - Office Visit |
| Out-of-Network | Covered same as Physician Services - Office Visit |
All plans have exclusions and limitations. For a summary of these exclusions and limitations, view the Summary of Benefits and Coverage.