Your Medical Benefits
Medical
Group # 00636233
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.
| LocalPlus Plan - LocalPlus | Open Access Plus Plan - OAPIN Fallout | LocalPlus IN Plan - LocalPlus IN | Open Access Plus Plan - OAP Fallout | OAP HDHPQ Plan - HDHPQ OAP Fallout | LocalPlus HDHPQ Plan - HDHPQ LocalPlus | |
|---|---|---|---|---|---|---|
| Plan Coinsurance | ||||||
| In-Network | Plan pays 80% | Plan pays 80% | Plan pays 80% | Plan pays 80% | Plan pays 100% | Plan pays 100% |
| Out-Of-Network | Plan pays 50% | Not Covered for all benefits | Not Covered for all benefits | Plan pays 50% | Plan pays 70% | Plan pays 70% |
| Individual Deductible | ||||||
| In-Network | Individual: $2,000 | Individual: $2,000 | Individual: $2,000 | Individual: $2,000 | Individual - Employee Only: $3,400 Individual - within a Family: $3,400 | Individual - Employee Only: $3,400 Individual - within a Family: $3,400 |
| Out-Of-Network | Individual: $5,000 | Not Covered for all benefits | Not Covered for all benefits | Individual: $5,000 | Individual - Employee Only: $3,400 Individual - within a Family: $3,400 | Individual - Employee Only: $3,400 Individual - within a Family: $3,400 |
| Family Deductible | ||||||
| In-Network | Family: $4,000 | Family: $6,000 | Family: $6,000 | Family: $4,000 | Family Maximum: $6,800 | Family Maximum: $6,800 |
| Out-Of-Network | Family: $10,000 | Not Covered for all benefits | Not Covered for all benefits | Family: $10,000 | Family Maximum: $6,800 | Family Maximum: $6,800 |
| Individual Out-of-Pocket | ||||||
| In-Network | Individual: $6,000 | Individual: $5,000 | Individual: $5,000 | Individual: $6,000 | Individual - Employee Only: $4,000 Individual - within a Family: $4,000 | Individual - Employee Only: $4,000 Individual - within a Family: $4,000 |
| Out-Of-Network | Individual: $10,000 | Not Covered for all benefits | Not Covered for all benefits | Individual: $10,000 | Individual - Employee Only: $8,000 Individual - within a Family: $8,000 | Individual - Employee Only: $8,000 Individual - within a Family: $8,000 |
| Family Out-of-Pocket | ||||||
| In-Network | Family: $12,000 | Family: $10,000 | Family: $10,000 | Family: $12,000 | Family Maximum: $8,000 | Family Maximum: $8,000 |
| Out-Of-Network | Family: $20,000 | Not Covered for all benefits | Not Covered for all benefits | Family: $20,000 | Family Maximum: $16,000 | Family Maximum: $16,000 |
| Primary Care Office Visit | ||||||
| In-Network | $25 copay, and plan pays 100% | $35 copay, and plan pays 100% | $35 copay, and plan pays 100% | $25 copay, and plan pays 100% | Plan pays 100% | Plan pays 100% |
| Out-Of-Network | Plan pays 50% | Not Covered for all benefits | Not Covered for all benefits | Plan pays 50% | Plan pays 70% | Plan pays 70% |
| Specialist Care Office Visit | ||||||
| In-Network | $50 copay, and plan pays 100% | $70 copay, and plan pays 100% | $70 copay, and plan pays 100% | $50 copay, and plan pays 100% | Plan pays 100% | Plan pays 100% |
| Out-Of-Network | Plan pays 50% | Not Covered for all benefits | Not Covered for all benefits | Plan pays 50% | Plan pays 70% | Plan pays 70% |
| Emergency Room | ||||||
| $250 copay, and plan pays 80% | $500 copay, and plan pays 100% | $500 copay, and plan pays 100% | $250 copay, and plan pays 80% | Plan pays 100% | Plan pays 100% | |
| Urgent Care | ||||||
| In-Network | $50 copay, and plan pays 100% | $70 copay, and plan pays 100% | $70 copay, and plan pays 100% | $50 copay, and plan pays 100% | Plan pays 100% | Plan pays 100% |
| Out-Of-Network | Plan pays 50% | Not Covered for all benefits | Not Covered for all benefits | Plan pays 50% | Plan pays 70% | Plan pays 70% |
| Outpatient Radiology | ||||||
| In-Network | Plan pays 100% | Plan pays 100% | Plan pays 100% | Plan pays 100% | Plan pays 100% | Plan pays 100% |
| Out-Of-Network | Plan pays 50% | Not Covered for all benefits | Not Covered for all benefits | Plan pays 50% | Plan pays 70% | Plan pays 70% |
| Independent Laboratory | ||||||
| In-Network | Plan pays 100% | Plan pays 100% | Plan pays 100% | Plan pays 100% | Plan pays 100% | Plan pays 100% |
| Out-Of-Network | Plan pays 50% | Not Covered for all benefits | Not Covered for all benefits | Plan pays 50% | Plan pays 70% | Plan pays 70% |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | ||||||
| In-Network | $25 copay, and plan pays 100% | $35 copay, and plan pays 100% | $35 copay, and plan pays 100% | $25 copay, and plan pays 100% | Plan pays 100% | Plan pays 100% |
| Out-Of-Network | Plan pays 50% | Not Covered for all benefits | Not Covered for all benefits | Plan pays 50% | Plan pays 70% | Plan pays 70% |
| Pharmacy Formulary | ||||||
| Advantage | Advantage | Advantage | Advantage | Advantage | Advantage | |
| Retail Pharmacy Customer Share | ||||||
| In-Network | Retail (per 30-day supply): Generic: You pay $20 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $90 | Retail (per 30-day supply): Generic: You pay $20 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $90 | Retail (per 30-day supply): Generic: You pay $20 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $90 | Retail (per 30-day supply): Generic: You pay $20 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $90 | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $35 Non-Preferred Brand: You pay $60 | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $35 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 | 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 $200 Retail and Home Delivery (per 90-day supply): Generic: You pay $60 Preferred Brand: You pay $150 Non-Preferred Brand: You pay $270 | Retail and Home Delivery (per 30-day supply): Specialty: You pay $200 Retail and Home Delivery (per 90-day supply): Generic: You pay $60 Preferred Brand: You pay $150 Non-Preferred Brand: You pay $270 | Retail and Home Delivery (per 30-day supply): Specialty: You pay $200 Retail and Home Delivery (per 90-day supply): Generic: You pay $60 Preferred Brand: You pay $150 Non-Preferred Brand: You pay $270 | Retail and Home Delivery (per 30-day supply): Specialty: You pay $200 Retail and Home Delivery (per 90-day supply): Generic: You pay $60 Preferred Brand: You pay $150 Non-Preferred Brand: You pay $270 | Retail and Home Delivery (per 90-day supply): Generic: You pay $25 Preferred Brand: You pay $88 Non-Preferred Brand: You pay $150 | Retail and Home Delivery (per 90-day supply): Generic: You pay $25 Preferred Brand: You pay $88 Non-Preferred Brand: You pay $150 |
| Out-Of-Network | Not Covered for all benefits | Not Covered for all benefits | Not Covered for all benefits | Not Covered for all benefits | Not Covered for all benefits | Not Covered for all benefits |
Plan Coinsurance
| LocalPlus Plan - LocalPlus | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAPIN Fallout | |
|---|---|
| In-Network | Plan pays 80% |
| LocalPlus IN Plan - LocalPlus IN | |
|---|---|
| In-Network | Plan pays 80% |
| Open Access Plus Plan - OAP Fallout | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAP Fallout | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 70% |
| LocalPlus HDHPQ Plan - HDHPQ LocalPlus | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 70% |
Individual Deductible
| LocalPlus Plan - LocalPlus | |
|---|---|
| In-Network | Individual: $2,000 |
| Out-of-Network | Individual: $5,000 |
| Open Access Plus Plan - OAPIN Fallout | |
|---|---|
| In-Network | Individual: $2,000 |
| LocalPlus IN Plan - LocalPlus IN | |
|---|---|
| In-Network | Individual: $2,000 |
| Open Access Plus Plan - OAP Fallout | |
|---|---|
| In-Network | Individual: $2,000 |
| Out-of-Network | Individual: $5,000 |
| OAP HDHPQ Plan - HDHPQ OAP Fallout | |
|---|---|
| In-Network | Individual - Employee Only: $3,400 Individual - within a Family: $3,400 |
| Out-of-Network | Individual - Employee Only: $3,400 Individual - within a Family: $3,400 |
| LocalPlus HDHPQ Plan - HDHPQ LocalPlus | |
|---|---|
| In-Network | Individual - Employee Only: $3,400 Individual - within a Family: $3,400 |
| Out-of-Network | Individual - Employee Only: $3,400 Individual - within a Family: $3,400 |
Family Deductible
| LocalPlus Plan - LocalPlus | |
|---|---|
| In-Network | Family: $4,000 |
| Out-of-Network | Family: $10,000 |
| Open Access Plus Plan - OAPIN Fallout | |
|---|---|
| In-Network | Family: $6,000 |
| LocalPlus IN Plan - LocalPlus IN | |
|---|---|
| In-Network | Family: $6,000 |
| Open Access Plus Plan - OAP Fallout | |
|---|---|
| In-Network | Family: $4,000 |
| Out-of-Network | Family: $10,000 |
| OAP HDHPQ Plan - HDHPQ OAP Fallout | |
|---|---|
| In-Network | Family Maximum: $6,800 |
| Out-of-Network | Family Maximum: $6,800 |
| LocalPlus HDHPQ Plan - HDHPQ LocalPlus | |
|---|---|
| In-Network | Family Maximum: $6,800 |
| Out-of-Network | Family Maximum: $6,800 |
Individual Out-of-Pocket
| LocalPlus Plan - LocalPlus | |
|---|---|
| In-Network | Individual: $6,000 |
| Out-of-Network | Individual: $10,000 |
| Open Access Plus Plan - OAPIN Fallout | |
|---|---|
| In-Network | Individual: $5,000 |
| LocalPlus IN Plan - LocalPlus IN | |
|---|---|
| In-Network | Individual: $5,000 |
| Open Access Plus Plan - OAP Fallout | |
|---|---|
| In-Network | Individual: $6,000 |
| Out-of-Network | Individual: $10,000 |
| OAP HDHPQ Plan - HDHPQ OAP Fallout | |
|---|---|
| In-Network | Individual - Employee Only: $4,000 Individual - within a Family: $4,000 |
| Out-of-Network | Individual - Employee Only: $8,000 Individual - within a Family: $8,000 |
| LocalPlus HDHPQ Plan - HDHPQ LocalPlus | |
|---|---|
| In-Network | Individual - Employee Only: $4,000 Individual - within a Family: $4,000 |
| Out-of-Network | Individual - Employee Only: $8,000 Individual - within a Family: $8,000 |
Family Out-of-Pocket
| LocalPlus Plan - LocalPlus | |
|---|---|
| In-Network | Family: $12,000 |
| Out-of-Network | Family: $20,000 |
| Open Access Plus Plan - OAPIN Fallout | |
|---|---|
| In-Network | Family: $10,000 |
| LocalPlus IN Plan - LocalPlus IN | |
|---|---|
| In-Network | Family: $10,000 |
| Open Access Plus Plan - OAP Fallout | |
|---|---|
| In-Network | Family: $12,000 |
| Out-of-Network | Family: $20,000 |
| OAP HDHPQ Plan - HDHPQ OAP Fallout | |
|---|---|
| In-Network | Family Maximum: $8,000 |
| Out-of-Network | Family Maximum: $16,000 |
| LocalPlus HDHPQ Plan - HDHPQ LocalPlus | |
|---|---|
| In-Network | Family Maximum: $8,000 |
| Out-of-Network | Family Maximum: $16,000 |
Primary Care Office Visit
| LocalPlus Plan - LocalPlus | |
|---|---|
| In-Network | $25 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAPIN Fallout | |
|---|---|
| In-Network | $35 copay, and plan pays 100% |
| LocalPlus IN Plan - LocalPlus IN | |
|---|---|
| In-Network | $35 copay, and plan pays 100% |
| Open Access Plus Plan - OAP Fallout | |
|---|---|
| In-Network | $25 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAP Fallout | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 70% |
| LocalPlus HDHPQ Plan - HDHPQ LocalPlus | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 70% |
Specialist Care Office Visit
| LocalPlus Plan - LocalPlus | |
|---|---|
| In-Network | $50 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAPIN Fallout | |
|---|---|
| In-Network | $70 copay, and plan pays 100% |
| LocalPlus IN Plan - LocalPlus IN | |
|---|---|
| In-Network | $70 copay, and plan pays 100% |
| Open Access Plus Plan - OAP Fallout | |
|---|---|
| In-Network | $50 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAP Fallout | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 70% |
| LocalPlus HDHPQ Plan - HDHPQ LocalPlus | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 70% |
Emergency Room
| LocalPlus Plan - LocalPlus | |
|---|---|
| $250 copay, and plan pays 80% |
| Open Access Plus Plan - OAPIN Fallout | |
|---|---|
| $500 copay, and plan pays 100% |
| LocalPlus IN Plan - LocalPlus IN | |
|---|---|
| $500 copay, and plan pays 100% |
| Open Access Plus Plan - OAP Fallout | |
|---|---|
| $250 copay, and plan pays 80% |
| OAP HDHPQ Plan - HDHPQ OAP Fallout | |
|---|---|
| Plan pays 100% |
| LocalPlus HDHPQ Plan - HDHPQ LocalPlus | |
|---|---|
| Plan pays 100% |
Urgent Care
| LocalPlus Plan - LocalPlus | |
|---|---|
| In-Network | $50 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAPIN Fallout | |
|---|---|
| In-Network | $70 copay, and plan pays 100% |
| LocalPlus IN Plan - LocalPlus IN | |
|---|---|
| In-Network | $70 copay, and plan pays 100% |
| Open Access Plus Plan - OAP Fallout | |
|---|---|
| In-Network | $50 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAP Fallout | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 70% |
| LocalPlus HDHPQ Plan - HDHPQ LocalPlus | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 70% |
Outpatient Radiology
| LocalPlus Plan - LocalPlus | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAPIN Fallout | |
|---|---|
| In-Network | Plan pays 100% |
| LocalPlus IN Plan - LocalPlus IN | |
|---|---|
| In-Network | Plan pays 100% |
| Open Access Plus Plan - OAP Fallout | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAP Fallout | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 70% |
| LocalPlus HDHPQ Plan - HDHPQ LocalPlus | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 70% |
Independent Laboratory
| LocalPlus Plan - LocalPlus | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAPIN Fallout | |
|---|---|
| In-Network | Plan pays 100% |
| LocalPlus IN Plan - LocalPlus IN | |
|---|---|
| In-Network | Plan pays 100% |
| Open Access Plus Plan - OAP Fallout | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAP Fallout | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 70% |
| LocalPlus HDHPQ Plan - HDHPQ LocalPlus | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 70% |
Outpatient Physical, Speech, Hearing, and Occupational Therapy
| LocalPlus Plan - LocalPlus | |
|---|---|
| In-Network | $25 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAPIN Fallout | |
|---|---|
| In-Network | $35 copay, and plan pays 100% |
| LocalPlus IN Plan - LocalPlus IN | |
|---|---|
| In-Network | $35 copay, and plan pays 100% |
| Open Access Plus Plan - OAP Fallout | |
|---|---|
| In-Network | $25 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAP Fallout | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 70% |
| LocalPlus HDHPQ Plan - HDHPQ LocalPlus | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 70% |
Pharmacy Formulary
| LocalPlus Plan - LocalPlus | |
|---|---|
| Advantage |
| Open Access Plus Plan - OAPIN Fallout | |
|---|---|
| Advantage |
| LocalPlus IN Plan - LocalPlus IN | |
|---|---|
| Advantage |
| Open Access Plus Plan - OAP Fallout | |
|---|---|
| Advantage |
| OAP HDHPQ Plan - HDHPQ OAP Fallout | |
|---|---|
| Advantage |
| LocalPlus HDHPQ Plan - HDHPQ LocalPlus | |
|---|---|
| Advantage |
Retail Pharmacy Customer Share
| LocalPlus Plan - LocalPlus | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $20 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $90 |
| Open Access Plus Plan - OAPIN Fallout | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $20 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $90 |
| LocalPlus IN Plan - LocalPlus IN | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $20 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $90 |
| Open Access Plus Plan - OAP Fallout | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $20 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $90 |
| OAP HDHPQ Plan - HDHPQ OAP Fallout | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $35 Non-Preferred Brand: You pay $60 |
| LocalPlus HDHPQ Plan - HDHPQ LocalPlus | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $35 Non-Preferred Brand: You pay $60 |
Home Delivery Pharmacy Customer Share
| LocalPlus Plan - LocalPlus | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay $200 Retail and Home Delivery (per 90-day supply): Generic: You pay $60 Preferred Brand: You pay $150 Non-Preferred Brand: You pay $270 |
| Open Access Plus Plan - OAPIN Fallout | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay $200 Retail and Home Delivery (per 90-day supply): Generic: You pay $60 Preferred Brand: You pay $150 Non-Preferred Brand: You pay $270 |
| LocalPlus IN Plan - LocalPlus IN | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay $200 Retail and Home Delivery (per 90-day supply): Generic: You pay $60 Preferred Brand: You pay $150 Non-Preferred Brand: You pay $270 |
| Open Access Plus Plan - OAP Fallout | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay $200 Retail and Home Delivery (per 90-day supply): Generic: You pay $60 Preferred Brand: You pay $150 Non-Preferred Brand: You pay $270 |
| OAP HDHPQ Plan - HDHPQ OAP Fallout | |
|---|---|
| In-Network | Retail and Home Delivery (per 90-day supply): Generic: You pay $25 Preferred Brand: You pay $88 Non-Preferred Brand: You pay $150 |
| LocalPlus HDHPQ Plan - HDHPQ LocalPlus | |
|---|---|
| In-Network | Retail and Home Delivery (per 90-day supply): Generic: You pay $25 Preferred Brand: You pay $88 Non-Preferred Brand: You pay $150 |
All plans have exclusions and limitations. For a summary of these exclusions and limitations, view the Summary of Benefits and Coverage.
Medical
Group # 00636233
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.
| LocalPlus Plan - LocalPlus | Open Access Plus Plan - OAPIN Fallout | LocalPlus IN Plan - LocalPlus IN | Open Access Plus Plan - OAP Fallout | OAP HDHPQ Plan - HDHPQ OAP Fallout | LocalPlus HDHPQ Plan - HDHPQ LocalPlus | |
|---|---|---|---|---|---|---|
| Plan Coinsurance | ||||||
| In-Network | Plan pays 80% | Plan pays 80% | Plan pays 80% | Plan pays 80% | Plan pays 100% | Plan pays 100% |
| Out-Of-Network | Plan pays 50% | Not Covered for all benefits | Not Covered for all benefits | Plan pays 50% | Plan pays 70% | Plan pays 70% |
| Individual Deductible | ||||||
| In-Network | Individual: $2,000 | Individual: $2,000 | Individual: $2,000 | Individual: $2,000 | Individual - Employee Only: $3,400 Individual - within a Family: $3,400 | Individual - Employee Only: $3,400 Individual - within a Family: $3,400 |
| Out-Of-Network | Individual: $5,000 | Not Covered for all benefits | Not Covered for all benefits | Individual: $5,000 | Individual - Employee Only: $3,400 Individual - within a Family: $3,400 | Individual - Employee Only: $3,400 Individual - within a Family: $3,400 |
| Family Deductible | ||||||
| In-Network | Family: $4,000 | Family: $6,000 | Family: $6,000 | Family: $4,000 | Family Maximum: $6,800 | Family Maximum: $6,800 |
| Out-Of-Network | Family: $10,000 | Not Covered for all benefits | Not Covered for all benefits | Family: $10,000 | Family Maximum: $6,800 | Family Maximum: $6,800 |
| Individual Out-of-Pocket | ||||||
| In-Network | Individual: $6,000 | Individual: $5,000 | Individual: $5,000 | Individual: $6,000 | Individual - Employee Only: $4,000 Individual - within a Family: $4,000 | Individual - Employee Only: $4,000 Individual - within a Family: $4,000 |
| Out-Of-Network | Individual: $10,000 | Not Covered for all benefits | Not Covered for all benefits | Individual: $10,000 | Individual - Employee Only: $8,000 Individual - within a Family: $8,000 | Individual - Employee Only: $8,000 Individual - within a Family: $8,000 |
| Family Out-of-Pocket | ||||||
| In-Network | Family: $12,000 | Family: $10,000 | Family: $10,000 | Family: $12,000 | Family Maximum: $8,000 | Family Maximum: $8,000 |
| Out-Of-Network | Family: $20,000 | Not Covered for all benefits | Not Covered for all benefits | Family: $20,000 | Family Maximum: $16,000 | Family Maximum: $16,000 |
| Primary Care Office Visit | ||||||
| In-Network | $25 copay, and plan pays 100% | $35 copay, and plan pays 100% | $35 copay, and plan pays 100% | $25 copay, and plan pays 100% | Plan pays 100% | Plan pays 100% |
| Out-Of-Network | Plan pays 50% | Not Covered for all benefits | Not Covered for all benefits | Plan pays 50% | Plan pays 70% | Plan pays 70% |
| Specialist Care Office Visit | ||||||
| In-Network | $50 copay, and plan pays 100% | $70 copay, and plan pays 100% | $70 copay, and plan pays 100% | $50 copay, and plan pays 100% | Plan pays 100% | Plan pays 100% |
| Out-Of-Network | Plan pays 50% | Not Covered for all benefits | Not Covered for all benefits | Plan pays 50% | Plan pays 70% | Plan pays 70% |
| Emergency Room | ||||||
| $250 copay, and plan pays 80% | $500 copay, and plan pays 100% | $500 copay, and plan pays 100% | $250 copay, and plan pays 80% | Plan pays 100% | Plan pays 100% | |
| Urgent Care | ||||||
| In-Network | $50 copay, and plan pays 100% | $70 copay, and plan pays 100% | $70 copay, and plan pays 100% | $50 copay, and plan pays 100% | Plan pays 100% | Plan pays 100% |
| Out-Of-Network | Plan pays 50% | Not Covered for all benefits | Not Covered for all benefits | Plan pays 50% | Plan pays 70% | Plan pays 70% |
| Outpatient Radiology | ||||||
| In-Network | Plan pays 100% | Plan pays 100% | Plan pays 100% | Plan pays 100% | Plan pays 100% | Plan pays 100% |
| Out-Of-Network | Plan pays 50% | Not Covered for all benefits | Not Covered for all benefits | Plan pays 50% | Plan pays 70% | Plan pays 70% |
| Independent Laboratory | ||||||
| In-Network | Plan pays 100% | Plan pays 100% | Plan pays 100% | Plan pays 100% | Plan pays 100% | Plan pays 100% |
| Out-Of-Network | Plan pays 50% | Not Covered for all benefits | Not Covered for all benefits | Plan pays 50% | Plan pays 70% | Plan pays 70% |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | ||||||
| In-Network | $25 copay, and plan pays 100% | $35 copay, and plan pays 100% | $35 copay, and plan pays 100% | $25 copay, and plan pays 100% | Plan pays 100% | Plan pays 100% |
| Out-Of-Network | Plan pays 50% | Not Covered for all benefits | Not Covered for all benefits | Plan pays 50% | Plan pays 70% | Plan pays 70% |
| Pharmacy Formulary | ||||||
| Advantage | Advantage | Advantage | Advantage | Advantage | Advantage | |
| Retail Pharmacy Customer Share | ||||||
| In-Network | Retail (per 30-day supply): Generic: You pay $20 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $90 | Retail (per 30-day supply): Generic: You pay $20 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $90 | Retail (per 30-day supply): Generic: You pay $20 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $90 | Retail (per 30-day supply): Generic: You pay $20 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $90 | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $35 Non-Preferred Brand: You pay $60 | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $35 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 | 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 $200 Retail and Home Delivery (per 90-day supply): Generic: You pay $60 Preferred Brand: You pay $150 Non-Preferred Brand: You pay $270 | Retail and Home Delivery (per 30-day supply): Specialty: You pay $200 Retail and Home Delivery (per 90-day supply): Generic: You pay $60 Preferred Brand: You pay $150 Non-Preferred Brand: You pay $270 | Retail and Home Delivery (per 30-day supply): Specialty: You pay $200 Retail and Home Delivery (per 90-day supply): Generic: You pay $60 Preferred Brand: You pay $150 Non-Preferred Brand: You pay $270 | Retail and Home Delivery (per 30-day supply): Specialty: You pay $200 Retail and Home Delivery (per 90-day supply): Generic: You pay $60 Preferred Brand: You pay $150 Non-Preferred Brand: You pay $270 | Retail and Home Delivery (per 90-day supply): Generic: You pay $25 Preferred Brand: You pay $88 Non-Preferred Brand: You pay $150 | Retail and Home Delivery (per 90-day supply): Generic: You pay $25 Preferred Brand: You pay $88 Non-Preferred Brand: You pay $150 |
| Out-Of-Network | Not Covered for all benefits | Not Covered for all benefits | Not Covered for all benefits | Not Covered for all benefits | Not Covered for all benefits | Not Covered for all benefits |
Plan Coinsurance
| LocalPlus Plan - LocalPlus | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAPIN Fallout | |
|---|---|
| In-Network | Plan pays 80% |
| LocalPlus IN Plan - LocalPlus IN | |
|---|---|
| In-Network | Plan pays 80% |
| Open Access Plus Plan - OAP Fallout | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAP Fallout | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 70% |
| LocalPlus HDHPQ Plan - HDHPQ LocalPlus | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 70% |
Individual Deductible
| LocalPlus Plan - LocalPlus | |
|---|---|
| In-Network | Individual: $2,000 |
| Out-of-Network | Individual: $5,000 |
| Open Access Plus Plan - OAPIN Fallout | |
|---|---|
| In-Network | Individual: $2,000 |
| LocalPlus IN Plan - LocalPlus IN | |
|---|---|
| In-Network | Individual: $2,000 |
| Open Access Plus Plan - OAP Fallout | |
|---|---|
| In-Network | Individual: $2,000 |
| Out-of-Network | Individual: $5,000 |
| OAP HDHPQ Plan - HDHPQ OAP Fallout | |
|---|---|
| In-Network | Individual - Employee Only: $3,400 Individual - within a Family: $3,400 |
| Out-of-Network | Individual - Employee Only: $3,400 Individual - within a Family: $3,400 |
| LocalPlus HDHPQ Plan - HDHPQ LocalPlus | |
|---|---|
| In-Network | Individual - Employee Only: $3,400 Individual - within a Family: $3,400 |
| Out-of-Network | Individual - Employee Only: $3,400 Individual - within a Family: $3,400 |
Family Deductible
| LocalPlus Plan - LocalPlus | |
|---|---|
| In-Network | Family: $4,000 |
| Out-of-Network | Family: $10,000 |
| Open Access Plus Plan - OAPIN Fallout | |
|---|---|
| In-Network | Family: $6,000 |
| LocalPlus IN Plan - LocalPlus IN | |
|---|---|
| In-Network | Family: $6,000 |
| Open Access Plus Plan - OAP Fallout | |
|---|---|
| In-Network | Family: $4,000 |
| Out-of-Network | Family: $10,000 |
| OAP HDHPQ Plan - HDHPQ OAP Fallout | |
|---|---|
| In-Network | Family Maximum: $6,800 |
| Out-of-Network | Family Maximum: $6,800 |
| LocalPlus HDHPQ Plan - HDHPQ LocalPlus | |
|---|---|
| In-Network | Family Maximum: $6,800 |
| Out-of-Network | Family Maximum: $6,800 |
Individual Out-of-Pocket
| LocalPlus Plan - LocalPlus | |
|---|---|
| In-Network | Individual: $6,000 |
| Out-of-Network | Individual: $10,000 |
| Open Access Plus Plan - OAPIN Fallout | |
|---|---|
| In-Network | Individual: $5,000 |
| LocalPlus IN Plan - LocalPlus IN | |
|---|---|
| In-Network | Individual: $5,000 |
| Open Access Plus Plan - OAP Fallout | |
|---|---|
| In-Network | Individual: $6,000 |
| Out-of-Network | Individual: $10,000 |
| OAP HDHPQ Plan - HDHPQ OAP Fallout | |
|---|---|
| In-Network | Individual - Employee Only: $4,000 Individual - within a Family: $4,000 |
| Out-of-Network | Individual - Employee Only: $8,000 Individual - within a Family: $8,000 |
| LocalPlus HDHPQ Plan - HDHPQ LocalPlus | |
|---|---|
| In-Network | Individual - Employee Only: $4,000 Individual - within a Family: $4,000 |
| Out-of-Network | Individual - Employee Only: $8,000 Individual - within a Family: $8,000 |
Family Out-of-Pocket
| LocalPlus Plan - LocalPlus | |
|---|---|
| In-Network | Family: $12,000 |
| Out-of-Network | Family: $20,000 |
| Open Access Plus Plan - OAPIN Fallout | |
|---|---|
| In-Network | Family: $10,000 |
| LocalPlus IN Plan - LocalPlus IN | |
|---|---|
| In-Network | Family: $10,000 |
| Open Access Plus Plan - OAP Fallout | |
|---|---|
| In-Network | Family: $12,000 |
| Out-of-Network | Family: $20,000 |
| OAP HDHPQ Plan - HDHPQ OAP Fallout | |
|---|---|
| In-Network | Family Maximum: $8,000 |
| Out-of-Network | Family Maximum: $16,000 |
| LocalPlus HDHPQ Plan - HDHPQ LocalPlus | |
|---|---|
| In-Network | Family Maximum: $8,000 |
| Out-of-Network | Family Maximum: $16,000 |
Primary Care Office Visit
| LocalPlus Plan - LocalPlus | |
|---|---|
| In-Network | $25 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAPIN Fallout | |
|---|---|
| In-Network | $35 copay, and plan pays 100% |
| LocalPlus IN Plan - LocalPlus IN | |
|---|---|
| In-Network | $35 copay, and plan pays 100% |
| Open Access Plus Plan - OAP Fallout | |
|---|---|
| In-Network | $25 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAP Fallout | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 70% |
| LocalPlus HDHPQ Plan - HDHPQ LocalPlus | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 70% |
Specialist Care Office Visit
| LocalPlus Plan - LocalPlus | |
|---|---|
| In-Network | $50 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAPIN Fallout | |
|---|---|
| In-Network | $70 copay, and plan pays 100% |
| LocalPlus IN Plan - LocalPlus IN | |
|---|---|
| In-Network | $70 copay, and plan pays 100% |
| Open Access Plus Plan - OAP Fallout | |
|---|---|
| In-Network | $50 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAP Fallout | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 70% |
| LocalPlus HDHPQ Plan - HDHPQ LocalPlus | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 70% |
Emergency Room
| LocalPlus Plan - LocalPlus | |
|---|---|
| $250 copay, and plan pays 80% |
| Open Access Plus Plan - OAPIN Fallout | |
|---|---|
| $500 copay, and plan pays 100% |
| LocalPlus IN Plan - LocalPlus IN | |
|---|---|
| $500 copay, and plan pays 100% |
| Open Access Plus Plan - OAP Fallout | |
|---|---|
| $250 copay, and plan pays 80% |
| OAP HDHPQ Plan - HDHPQ OAP Fallout | |
|---|---|
| Plan pays 100% |
| LocalPlus HDHPQ Plan - HDHPQ LocalPlus | |
|---|---|
| Plan pays 100% |
Urgent Care
| LocalPlus Plan - LocalPlus | |
|---|---|
| In-Network | $50 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAPIN Fallout | |
|---|---|
| In-Network | $70 copay, and plan pays 100% |
| LocalPlus IN Plan - LocalPlus IN | |
|---|---|
| In-Network | $70 copay, and plan pays 100% |
| Open Access Plus Plan - OAP Fallout | |
|---|---|
| In-Network | $50 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAP Fallout | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 70% |
| LocalPlus HDHPQ Plan - HDHPQ LocalPlus | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 70% |
Outpatient Radiology
| LocalPlus Plan - LocalPlus | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAPIN Fallout | |
|---|---|
| In-Network | Plan pays 100% |
| LocalPlus IN Plan - LocalPlus IN | |
|---|---|
| In-Network | Plan pays 100% |
| Open Access Plus Plan - OAP Fallout | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAP Fallout | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 70% |
| LocalPlus HDHPQ Plan - HDHPQ LocalPlus | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 70% |
Independent Laboratory
| LocalPlus Plan - LocalPlus | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAPIN Fallout | |
|---|---|
| In-Network | Plan pays 100% |
| LocalPlus IN Plan - LocalPlus IN | |
|---|---|
| In-Network | Plan pays 100% |
| Open Access Plus Plan - OAP Fallout | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAP Fallout | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 70% |
| LocalPlus HDHPQ Plan - HDHPQ LocalPlus | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 70% |
Outpatient Physical, Speech, Hearing, and Occupational Therapy
| LocalPlus Plan - LocalPlus | |
|---|---|
| In-Network | $25 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAPIN Fallout | |
|---|---|
| In-Network | $35 copay, and plan pays 100% |
| LocalPlus IN Plan - LocalPlus IN | |
|---|---|
| In-Network | $35 copay, and plan pays 100% |
| Open Access Plus Plan - OAP Fallout | |
|---|---|
| In-Network | $25 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAP Fallout | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 70% |
| LocalPlus HDHPQ Plan - HDHPQ LocalPlus | |
|---|---|
| In-Network | Plan pays 100% |
| Out-of-Network | Plan pays 70% |
Pharmacy Formulary
| LocalPlus Plan - LocalPlus | |
|---|---|
| Advantage |
| Open Access Plus Plan - OAPIN Fallout | |
|---|---|
| Advantage |
| LocalPlus IN Plan - LocalPlus IN | |
|---|---|
| Advantage |
| Open Access Plus Plan - OAP Fallout | |
|---|---|
| Advantage |
| OAP HDHPQ Plan - HDHPQ OAP Fallout | |
|---|---|
| Advantage |
| LocalPlus HDHPQ Plan - HDHPQ LocalPlus | |
|---|---|
| Advantage |
Retail Pharmacy Customer Share
| LocalPlus Plan - LocalPlus | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $20 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $90 |
| Open Access Plus Plan - OAPIN Fallout | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $20 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $90 |
| LocalPlus IN Plan - LocalPlus IN | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $20 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $90 |
| Open Access Plus Plan - OAP Fallout | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $20 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $90 |
| OAP HDHPQ Plan - HDHPQ OAP Fallout | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $35 Non-Preferred Brand: You pay $60 |
| LocalPlus HDHPQ Plan - HDHPQ LocalPlus | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $35 Non-Preferred Brand: You pay $60 |
Home Delivery Pharmacy Customer Share
| LocalPlus Plan - LocalPlus | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay $200 Retail and Home Delivery (per 90-day supply): Generic: You pay $60 Preferred Brand: You pay $150 Non-Preferred Brand: You pay $270 |
| Open Access Plus Plan - OAPIN Fallout | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay $200 Retail and Home Delivery (per 90-day supply): Generic: You pay $60 Preferred Brand: You pay $150 Non-Preferred Brand: You pay $270 |
| LocalPlus IN Plan - LocalPlus IN | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay $200 Retail and Home Delivery (per 90-day supply): Generic: You pay $60 Preferred Brand: You pay $150 Non-Preferred Brand: You pay $270 |
| Open Access Plus Plan - OAP Fallout | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay $200 Retail and Home Delivery (per 90-day supply): Generic: You pay $60 Preferred Brand: You pay $150 Non-Preferred Brand: You pay $270 |
| OAP HDHPQ Plan - HDHPQ OAP Fallout | |
|---|---|
| In-Network | Retail and Home Delivery (per 90-day supply): Generic: You pay $25 Preferred Brand: You pay $88 Non-Preferred Brand: You pay $150 |
| LocalPlus HDHPQ Plan - HDHPQ LocalPlus | |
|---|---|
| In-Network | Retail and Home Delivery (per 90-day supply): Generic: You pay $25 Preferred Brand: You pay $88 Non-Preferred Brand: You pay $150 |
All plans have exclusions and limitations. For a summary of these exclusions and limitations, view the Summary of Benefits and Coverage.