Your Medical Benefits
Open Access Plus - OAP Base
Benefit Summary
Group # 00651525
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 - OAP Base | |
| Plan Coinsurance | Plan pays 80% | Plan pays 60% |
| Individual Deductible | Individual: $1,000 | Individual: $2,000 |
| Family Deductible | Family: $3,000 | Family: $6,000 |
| Individual Out-of-Pocket | Individual: $5,250 | Individual: $10,500 |
| Family Out-of-Pocket | Family: $10,500 | Family: $21,000 |
| Primary Care Office Visit | $30 copay, and plan pays 100% | Plan pays 60% |
| Specialist Care Office Visit | $40 copay, and plan pays 100% | Plan pays 60% |
| Emergency Room | Plan pays 80% | |
| Urgent Care | $30 copay, and plan pays 100% | Plan pays 60% |
| Outpatient Radiology | Plan pays 80% | Plan pays 60% |
| Independent Laboratory | Plan pays 80% | Plan pays 60% |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | $40 copay, and plan pays 100% | Plan pays 60% |
| Pharmacy Formulary | Advantage | |
| Retail Pharmacy Customer Share | 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: You pay 25% Your plan pays 75% |
| Home Delivery Pharmacy Customer Share | 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: 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 # 00651525
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 - OAP Base | |
| Plan Coinsurance | Plan pays 80% | Plan pays 60% |
| Individual Deductible | Individual: $1,000 | Individual: $2,000 |
| Family Deductible | Family: $3,000 | Family: $6,000 |
| Individual Out-of-Pocket | Individual: $5,250 | Individual: $10,500 |
| Family Out-of-Pocket | Family: $10,500 | Family: $21,000 |
| Primary Care Office Visit | $30 copay, and plan pays 100% | Plan pays 60% |
| Specialist Care Office Visit | $40 copay, and plan pays 100% | Plan pays 60% |
| Emergency Room | Plan pays 80% | |
| Urgent Care | $30 copay, and plan pays 100% | Plan pays 60% |
| Outpatient Radiology | Plan pays 80% | Plan pays 60% |
| Independent Laboratory | Plan pays 80% | Plan pays 60% |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | $40 copay, and plan pays 100% | Plan pays 60% |
| Pharmacy Formulary | Advantage | |
| Retail Pharmacy Customer Share | 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: You pay 25% Your plan pays 75% |
| Home Delivery Pharmacy Customer Share | 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: Not Covered |
All plans have exclusions and limitations. For a summary of these exclusions and limitations, view the Summary of Benefits and Coverage.