Your Medical Benefits
Medical
Group # 00651525
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 - HDHPQ OAP | Open Access Plus - OAP Base | Open Access Plus - OAP Buy Up | Open Access Plus In-Network - OAPIN | |
|---|---|---|---|---|
| Plan Coinsurance | ||||
| In-Network | Plan pays 80% | Plan pays 80% | Plan pays 80% | Plan pays 100% |
| Out-Of-Network | Plan pays 60% | Plan pays 60% | Plan pays 60% | Not Covered for all benefits |
| Individual Deductible | ||||
| In-Network | Individual - Employee Only: $2,000 | Individual: $1,000 | Individual: $500 | Individual: None |
| Out-Of-Network | Individual - Employee Only: $4,000 | Individual: $2,000 | Individual: $750 | Not Covered for all benefits |
| Family Deductible | ||||
| In-Network | Family Maximum: $4,000 | Family: $3,000 | Family: $1,000 | Family: None |
| Out-Of-Network | Family Maximum: $8,000 | Family: $6,000 | Family: $1,500 | Not Covered for all benefits |
| Individual Out-of-Pocket | ||||
| In-Network | Individual - Employee Only: $3,500 | Individual: $5,250 | Individual: $3,000 | Individual: $2,500 |
| Out-Of-Network | Individual - Employee Only: $6,000 | Individual: $10,500 | Individual: $10,250 | Not Covered for all benefits |
| Family Out-of-Pocket | ||||
| In-Network | Family Maximum: $7,000 | Family: $10,500 | Family: $6,000 | Family: $5,000 |
| Out-Of-Network | Family Maximum: $12,000 | Family: $21,000 | Family: $20,500 | Not Covered for all benefits |
| Primary Care Office Visit | ||||
| In-Network | Plan pays 80% | $30 copay, and plan pays 100% | $20 copay, and plan pays 100% | $20 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 60% | Plan pays 60% | Plan pays 60% | Not Covered for all benefits |
| Specialist Care Office Visit | ||||
| In-Network | Plan pays 80% | $40 copay, and plan pays 100% | $30 copay, and plan pays 100% | $25 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 60% | Plan pays 60% | Plan pays 60% | Not Covered for all benefits |
| Emergency Room | ||||
| $150 copay, and plan pays 100% | Plan pays 80% | Plan pays 80% | $150 copay, and plan pays 100% | |
| Urgent Care | ||||
| In-Network | Plan pays 80% | $30 copay, and plan pays 100% | $20 copay, and plan pays 100% | $20 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 60% | Plan pays 60% | Plan pays 60% | Not Covered for all benefits |
| Outpatient Radiology | ||||
| In-Network | Plan pays 80% | Plan pays 80% | Plan pays 80% | Plan pays 100% |
| Out-Of-Network | Plan pays 60% | Plan pays 60% | Plan pays 60% | Not Covered for all benefits |
| Independent Laboratory | ||||
| In-Network | Plan pays 80% | Plan pays 80% | Plan pays 80% | Plan pays 100% |
| Out-Of-Network | Plan pays 60% | Plan pays 60% | Plan pays 60% | Not Covered for all benefits |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | ||||
| In-Network | Plan pays 80% | $40 copay, and plan pays 100% | $30 copay, and plan pays 100% | $25 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 60% | Plan pays 60% | Plan pays 60% | Not Covered for all benefits |
| Pharmacy Formulary | ||||
| Advantage | Advantage | Advantage | Advantage | |
| Retail Pharmacy Customer Share | ||||
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $25 Non-Preferred Brand: You pay $40 Specialty: You pay 30% up to a maximum of $250 Retail (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $75 Non-Preferred Brand: You pay $120 | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $30 Non-Preferred Brand: You pay $50 Specialty: You pay 30% up to a maximum of $250 Retail (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $90 Non-Preferred Brand: You pay $150 | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $30 Non-Preferred Brand: You pay $50 Specialty: You pay 30% up to a maximum of $250 Retail (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $90 Non-Preferred Brand: You pay $150 | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $30 Non-Preferred Brand: You pay $60 Specialty: You pay 20% up to a maximum of $250 Retail (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $90 Non-Preferred Brand: You pay $180 |
| Out-Of-Network | Retail: You pay 25% Your plan pays 75% | Retail: You pay 25% Your plan pays 75% | Retail: You pay 25% Your plan pays 75% | Not Covered for all benefits |
| Home Delivery Pharmacy Customer Share | ||||
| In-Network | Home Delivery (per 90-day supply): Generic: You pay $20 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $80 Home Delivery (per 30-day supply): Specialty: You pay 30% up to a maximum of $250 | Home Delivery (per 90-day supply): Generic: You pay $20 Preferred Brand: You pay $60 Non-Preferred Brand: You pay $100 Home Delivery (per 30-day supply): Specialty: You pay 30% up to a maximum of $250 | Home Delivery (per 90-day supply): Generic: You pay $20 Preferred Brand: You pay $60 Non-Preferred Brand: You pay $100 Home Delivery (per 30-day supply): Specialty: You pay 30% up to a maximum of $250 | Home Delivery (per 90-day supply): Generic: You pay $20 Preferred Brand: You pay $60 Non-Preferred Brand: You pay $120 Home Delivery (per 30-day supply): Specialty: You pay 20% up to a maximum of $250 |
| Out-Of-Network | Home Delivery: Not Covered | Home Delivery: Not Covered | Home Delivery: Not Covered | Not Covered for all benefits |
Plan Coinsurance
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - OAP Base | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - OAP Buy Up | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | Plan pays 100% |
Individual Deductible
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Individual - Employee Only: $2,000 |
| Out-of-Network | Individual - Employee Only: $4,000 |
| Open Access Plus - OAP Base | |
|---|---|
| In-Network | Individual: $1,000 |
| Out-of-Network | Individual: $2,000 |
| Open Access Plus - OAP Buy Up | |
|---|---|
| In-Network | Individual: $500 |
| Out-of-Network | Individual: $750 |
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | Individual: None |
Family Deductible
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Family Maximum: $4,000 |
| Out-of-Network | Family Maximum: $8,000 |
| Open Access Plus - OAP Base | |
|---|---|
| In-Network | Family: $3,000 |
| Out-of-Network | Family: $6,000 |
| Open Access Plus - OAP Buy Up | |
|---|---|
| In-Network | Family: $1,000 |
| Out-of-Network | Family: $1,500 |
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | Family: None |
Individual Out-of-Pocket
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Individual - Employee Only: $3,500 |
| Out-of-Network | Individual - Employee Only: $6,000 |
| Open Access Plus - OAP Base | |
|---|---|
| In-Network | Individual: $5,250 |
| Out-of-Network | Individual: $10,500 |
| Open Access Plus - OAP Buy Up | |
|---|---|
| In-Network | Individual: $3,000 |
| Out-of-Network | Individual: $10,250 |
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | Individual: $2,500 |
Family Out-of-Pocket
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Family Maximum: $7,000 |
| Out-of-Network | Family Maximum: $12,000 |
| Open Access Plus - OAP Base | |
|---|---|
| In-Network | Family: $10,500 |
| Out-of-Network | Family: $21,000 |
| Open Access Plus - OAP Buy Up | |
|---|---|
| In-Network | Family: $6,000 |
| Out-of-Network | Family: $20,500 |
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | Family: $5,000 |
Primary Care Office Visit
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - OAP Base | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - OAP Buy Up | |
|---|---|
| In-Network | $20 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | $20 copay, and plan pays 100% |
Specialist Care Office Visit
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - OAP Base | |
|---|---|
| In-Network | $40 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - OAP Buy Up | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | $25 copay, and plan pays 100% |
Emergency Room
| Open Access Plus - HDHPQ OAP | |
|---|---|
| $150 copay, and plan pays 100% |
| Open Access Plus - OAP Base | |
|---|---|
| Plan pays 80% |
| Open Access Plus - OAP Buy Up | |
|---|---|
| Plan pays 80% |
| Open Access Plus In-Network - OAPIN | |
|---|---|
| $150 copay, and plan pays 100% |
Urgent Care
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - OAP Base | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - OAP Buy Up | |
|---|---|
| In-Network | $20 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | $20 copay, and plan pays 100% |
Outpatient Radiology
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - OAP Base | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - OAP Buy Up | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | Plan pays 100% |
Independent Laboratory
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - OAP Base | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - OAP Buy Up | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | Plan pays 100% |
Outpatient Physical, Speech, Hearing, and Occupational Therapy
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - OAP Base | |
|---|---|
| In-Network | $40 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - OAP Buy Up | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | $25 copay, and plan pays 100% |
Pharmacy Formulary
| Open Access Plus - HDHPQ OAP | |
|---|---|
| Advantage |
| Open Access Plus - OAP Base | |
|---|---|
| Advantage |
| Open Access Plus - OAP Buy Up | |
|---|---|
| Advantage |
| Open Access Plus In-Network - OAPIN | |
|---|---|
| Advantage |
Retail Pharmacy Customer Share
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $25 Non-Preferred Brand: You pay $40 Specialty: You pay 30% up to a maximum of $250 Retail (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $75 Non-Preferred Brand: You pay $120 |
| Out-of-Network | Retail: You pay 25% Your plan pays 75% |
| Open Access Plus - OAP Base | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $30 Non-Preferred Brand: You pay $50 Specialty: You pay 30% up to a maximum of $250 Retail (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $90 Non-Preferred Brand: You pay $150 |
| Out-of-Network | Retail: You pay 25% Your plan pays 75% |
| Open Access Plus - OAP Buy Up | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $30 Non-Preferred Brand: You pay $50 Specialty: You pay 30% up to a maximum of $250 Retail (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $90 Non-Preferred Brand: You pay $150 |
| Out-of-Network | Retail: You pay 25% Your plan pays 75% |
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $30 Non-Preferred Brand: You pay $60 Specialty: You pay 20% up to a maximum of $250 Retail (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $90 Non-Preferred Brand: You pay $180 |
Home Delivery Pharmacy Customer Share
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Home Delivery (per 90-day supply): Generic: You pay $20 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $80 Home Delivery (per 30-day supply): Specialty: You pay 30% up to a maximum of $250 |
| Out-of-Network | Home Delivery: Not Covered |
| Open Access Plus - OAP Base | |
|---|---|
| In-Network | Home Delivery (per 90-day supply): Generic: You pay $20 Preferred Brand: You pay $60 Non-Preferred Brand: You pay $100 Home Delivery (per 30-day supply): Specialty: You pay 30% up to a maximum of $250 |
| Out-of-Network | Home Delivery: Not Covered |
| Open Access Plus - OAP Buy Up | |
|---|---|
| In-Network | Home Delivery (per 90-day supply): Generic: You pay $20 Preferred Brand: You pay $60 Non-Preferred Brand: You pay $100 Home Delivery (per 30-day supply): Specialty: You pay 30% up to a maximum of $250 |
| Out-of-Network | Home Delivery: Not Covered |
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | Home Delivery (per 90-day supply): Generic: You pay $20 Preferred Brand: You pay $60 Non-Preferred Brand: You pay $120 Home Delivery (per 30-day supply): Specialty: You pay 20% up to a maximum of $250 |
All plans have exclusions and limitations. For a summary of these exclusions and limitations, view the Summary of Benefits and Coverage.
Medical
Group # 00651525
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 - HDHPQ OAP | Open Access Plus - OAP Base | Open Access Plus - OAP Buy Up | Open Access Plus In-Network - OAPIN | |
|---|---|---|---|---|
| Plan Coinsurance | ||||
| In-Network | Plan pays 80% | Plan pays 80% | Plan pays 80% | Plan pays 100% |
| Out-Of-Network | Plan pays 60% | Plan pays 60% | Plan pays 60% | Not Covered for all benefits |
| Individual Deductible | ||||
| In-Network | Individual - Employee Only: $2,000 | Individual: $1,000 | Individual: $500 | Individual: None |
| Out-Of-Network | Individual - Employee Only: $4,000 | Individual: $2,000 | Individual: $750 | Not Covered for all benefits |
| Family Deductible | ||||
| In-Network | Family Maximum: $4,000 | Family: $3,000 | Family: $1,000 | Family: None |
| Out-Of-Network | Family Maximum: $8,000 | Family: $6,000 | Family: $1,500 | Not Covered for all benefits |
| Individual Out-of-Pocket | ||||
| In-Network | Individual - Employee Only: $3,500 | Individual: $5,250 | Individual: $3,000 | Individual: $2,500 |
| Out-Of-Network | Individual - Employee Only: $6,000 | Individual: $10,500 | Individual: $10,250 | Not Covered for all benefits |
| Family Out-of-Pocket | ||||
| In-Network | Family Maximum: $7,000 | Family: $10,500 | Family: $6,000 | Family: $5,000 |
| Out-Of-Network | Family Maximum: $12,000 | Family: $21,000 | Family: $20,500 | Not Covered for all benefits |
| Primary Care Office Visit | ||||
| In-Network | Plan pays 80% | $30 copay, and plan pays 100% | $20 copay, and plan pays 100% | $20 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 60% | Plan pays 60% | Plan pays 60% | Not Covered for all benefits |
| Specialist Care Office Visit | ||||
| In-Network | Plan pays 80% | $40 copay, and plan pays 100% | $30 copay, and plan pays 100% | $25 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 60% | Plan pays 60% | Plan pays 60% | Not Covered for all benefits |
| Emergency Room | ||||
| $150 copay, and plan pays 100% | Plan pays 80% | Plan pays 80% | $150 copay, and plan pays 100% | |
| Urgent Care | ||||
| In-Network | Plan pays 80% | $30 copay, and plan pays 100% | $20 copay, and plan pays 100% | $20 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 60% | Plan pays 60% | Plan pays 60% | Not Covered for all benefits |
| Outpatient Radiology | ||||
| In-Network | Plan pays 80% | Plan pays 80% | Plan pays 80% | Plan pays 100% |
| Out-Of-Network | Plan pays 60% | Plan pays 60% | Plan pays 60% | Not Covered for all benefits |
| Independent Laboratory | ||||
| In-Network | Plan pays 80% | Plan pays 80% | Plan pays 80% | Plan pays 100% |
| Out-Of-Network | Plan pays 60% | Plan pays 60% | Plan pays 60% | Not Covered for all benefits |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | ||||
| In-Network | Plan pays 80% | $40 copay, and plan pays 100% | $30 copay, and plan pays 100% | $25 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 60% | Plan pays 60% | Plan pays 60% | Not Covered for all benefits |
| Pharmacy Formulary | ||||
| Advantage | Advantage | Advantage | Advantage | |
| Retail Pharmacy Customer Share | ||||
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $25 Non-Preferred Brand: You pay $40 Specialty: You pay 30% up to a maximum of $250 Retail (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $75 Non-Preferred Brand: You pay $120 | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $30 Non-Preferred Brand: You pay $50 Specialty: You pay 30% up to a maximum of $250 Retail (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $90 Non-Preferred Brand: You pay $150 | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $30 Non-Preferred Brand: You pay $50 Specialty: You pay 30% up to a maximum of $250 Retail (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $90 Non-Preferred Brand: You pay $150 | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $30 Non-Preferred Brand: You pay $60 Specialty: You pay 20% up to a maximum of $250 Retail (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $90 Non-Preferred Brand: You pay $180 |
| Out-Of-Network | Retail: You pay 25% Your plan pays 75% | Retail: You pay 25% Your plan pays 75% | Retail: You pay 25% Your plan pays 75% | Not Covered for all benefits |
| Home Delivery Pharmacy Customer Share | ||||
| In-Network | Home Delivery (per 90-day supply): Generic: You pay $20 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $80 Home Delivery (per 30-day supply): Specialty: You pay 30% up to a maximum of $250 | Home Delivery (per 90-day supply): Generic: You pay $20 Preferred Brand: You pay $60 Non-Preferred Brand: You pay $100 Home Delivery (per 30-day supply): Specialty: You pay 30% up to a maximum of $250 | Home Delivery (per 90-day supply): Generic: You pay $20 Preferred Brand: You pay $60 Non-Preferred Brand: You pay $100 Home Delivery (per 30-day supply): Specialty: You pay 30% up to a maximum of $250 | Home Delivery (per 90-day supply): Generic: You pay $20 Preferred Brand: You pay $60 Non-Preferred Brand: You pay $120 Home Delivery (per 30-day supply): Specialty: You pay 20% up to a maximum of $250 |
| Out-Of-Network | Home Delivery: Not Covered | Home Delivery: Not Covered | Home Delivery: Not Covered | Not Covered for all benefits |
Plan Coinsurance
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - OAP Base | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - OAP Buy Up | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | Plan pays 100% |
Individual Deductible
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Individual - Employee Only: $2,000 |
| Out-of-Network | Individual - Employee Only: $4,000 |
| Open Access Plus - OAP Base | |
|---|---|
| In-Network | Individual: $1,000 |
| Out-of-Network | Individual: $2,000 |
| Open Access Plus - OAP Buy Up | |
|---|---|
| In-Network | Individual: $500 |
| Out-of-Network | Individual: $750 |
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | Individual: None |
Family Deductible
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Family Maximum: $4,000 |
| Out-of-Network | Family Maximum: $8,000 |
| Open Access Plus - OAP Base | |
|---|---|
| In-Network | Family: $3,000 |
| Out-of-Network | Family: $6,000 |
| Open Access Plus - OAP Buy Up | |
|---|---|
| In-Network | Family: $1,000 |
| Out-of-Network | Family: $1,500 |
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | Family: None |
Individual Out-of-Pocket
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Individual - Employee Only: $3,500 |
| Out-of-Network | Individual - Employee Only: $6,000 |
| Open Access Plus - OAP Base | |
|---|---|
| In-Network | Individual: $5,250 |
| Out-of-Network | Individual: $10,500 |
| Open Access Plus - OAP Buy Up | |
|---|---|
| In-Network | Individual: $3,000 |
| Out-of-Network | Individual: $10,250 |
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | Individual: $2,500 |
Family Out-of-Pocket
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Family Maximum: $7,000 |
| Out-of-Network | Family Maximum: $12,000 |
| Open Access Plus - OAP Base | |
|---|---|
| In-Network | Family: $10,500 |
| Out-of-Network | Family: $21,000 |
| Open Access Plus - OAP Buy Up | |
|---|---|
| In-Network | Family: $6,000 |
| Out-of-Network | Family: $20,500 |
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | Family: $5,000 |
Primary Care Office Visit
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - OAP Base | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - OAP Buy Up | |
|---|---|
| In-Network | $20 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | $20 copay, and plan pays 100% |
Specialist Care Office Visit
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - OAP Base | |
|---|---|
| In-Network | $40 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - OAP Buy Up | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | $25 copay, and plan pays 100% |
Emergency Room
| Open Access Plus - HDHPQ OAP | |
|---|---|
| $150 copay, and plan pays 100% |
| Open Access Plus - OAP Base | |
|---|---|
| Plan pays 80% |
| Open Access Plus - OAP Buy Up | |
|---|---|
| Plan pays 80% |
| Open Access Plus In-Network - OAPIN | |
|---|---|
| $150 copay, and plan pays 100% |
Urgent Care
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - OAP Base | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - OAP Buy Up | |
|---|---|
| In-Network | $20 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | $20 copay, and plan pays 100% |
Outpatient Radiology
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - OAP Base | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - OAP Buy Up | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | Plan pays 100% |
Independent Laboratory
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - OAP Base | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - OAP Buy Up | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | Plan pays 100% |
Outpatient Physical, Speech, Hearing, and Occupational Therapy
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 80% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - OAP Base | |
|---|---|
| In-Network | $40 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus - OAP Buy Up | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| Out-of-Network | Plan pays 60% |
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | $25 copay, and plan pays 100% |
Pharmacy Formulary
| Open Access Plus - HDHPQ OAP | |
|---|---|
| Advantage |
| Open Access Plus - OAP Base | |
|---|---|
| Advantage |
| Open Access Plus - OAP Buy Up | |
|---|---|
| Advantage |
| Open Access Plus In-Network - OAPIN | |
|---|---|
| Advantage |
Retail Pharmacy Customer Share
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $25 Non-Preferred Brand: You pay $40 Specialty: You pay 30% up to a maximum of $250 Retail (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $75 Non-Preferred Brand: You pay $120 |
| Out-of-Network | Retail: You pay 25% Your plan pays 75% |
| Open Access Plus - OAP Base | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $30 Non-Preferred Brand: You pay $50 Specialty: You pay 30% up to a maximum of $250 Retail (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $90 Non-Preferred Brand: You pay $150 |
| Out-of-Network | Retail: You pay 25% Your plan pays 75% |
| Open Access Plus - OAP Buy Up | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $30 Non-Preferred Brand: You pay $50 Specialty: You pay 30% up to a maximum of $250 Retail (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $90 Non-Preferred Brand: You pay $150 |
| Out-of-Network | Retail: You pay 25% Your plan pays 75% |
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $10 Preferred Brand: You pay $30 Non-Preferred Brand: You pay $60 Specialty: You pay 20% up to a maximum of $250 Retail (per 90-day supply): Generic: You pay $30 Preferred Brand: You pay $90 Non-Preferred Brand: You pay $180 |
Home Delivery Pharmacy Customer Share
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Home Delivery (per 90-day supply): Generic: You pay $20 Preferred Brand: You pay $50 Non-Preferred Brand: You pay $80 Home Delivery (per 30-day supply): Specialty: You pay 30% up to a maximum of $250 |
| Out-of-Network | Home Delivery: Not Covered |
| Open Access Plus - OAP Base | |
|---|---|
| In-Network | Home Delivery (per 90-day supply): Generic: You pay $20 Preferred Brand: You pay $60 Non-Preferred Brand: You pay $100 Home Delivery (per 30-day supply): Specialty: You pay 30% up to a maximum of $250 |
| Out-of-Network | Home Delivery: Not Covered |
| Open Access Plus - OAP Buy Up | |
|---|---|
| In-Network | Home Delivery (per 90-day supply): Generic: You pay $20 Preferred Brand: You pay $60 Non-Preferred Brand: You pay $100 Home Delivery (per 30-day supply): Specialty: You pay 30% up to a maximum of $250 |
| Out-of-Network | Home Delivery: Not Covered |
| Open Access Plus In-Network - OAPIN | |
|---|---|
| In-Network | Home Delivery (per 90-day supply): Generic: You pay $20 Preferred Brand: You pay $60 Non-Preferred Brand: You pay $120 Home Delivery (per 30-day supply): Specialty: You pay 20% up to a maximum of $250 |
All plans have exclusions and limitations. For a summary of these exclusions and limitations, view the Summary of Benefits and Coverage.