Your Medical Benefits
Medical
Group # 00621855
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 | |
|---|---|---|
| Plan Coinsurance | ||
| In-Network | Plan pays 90% | Plan pays 90% |
| Out-Of-Network | Plan pays 70% | Plan pays 70% |
| Individual Deductible | ||
| In-Network | Individual - Employee Only: $1,700 Individual - within a Family: $3,400 | Individual: $500 |
| Out-Of-Network | Individual - Employee Only: $3,000 Individual - within a Family: $5,600 | Individual: $1,000 |
| Family Deductible | ||
| In-Network | Family Maximum: $3,400 | Family: $1,000 |
| Out-Of-Network | Family Maximum: $6,000 | Family: $2,000 |
| Individual Out-of-Pocket | ||
| In-Network | Individual - Employee Only: $3,000 Individual - within a Family: $3,400 | Individual: $2,500 |
| Out-Of-Network | Individual - Employee Only: $6,000 Individual - within a Family: $6,000 | Individual: $5,000 |
| Family Out-of-Pocket | ||
| In-Network | Family Maximum: $6,000 | Family: $5,000 |
| Out-Of-Network | Family Maximum: $12,000 | Family: $10,000 |
| Primary Care Office Visit | ||
| In-Network | Plan pays 90% | $20 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 70% | Plan pays 70% |
| Specialist Care Office Visit | ||
| In-Network | Plan pays 90% | $25 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 70% | Plan pays 70% |
| Emergency Room | ||
| Plan pays 90% | $100 copay, and plan pays 100% | |
| Urgent Care | ||
| In-Network | Plan pays 90% | $40 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 70% | Plan pays 70% |
| Outpatient Radiology | ||
| In-Network | Plan pays 90% | Plan pays 90% |
| Out-Of-Network | Plan pays 70% | Plan pays 70% |
| Independent Laboratory | ||
| In-Network | Plan pays 90% | Plan pays 90% |
| Out-Of-Network | Plan pays 70% | Plan pays 70% |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | ||
| In-Network | Plan pays 90% | $25 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 70% | Plan pays 70% |
| Pharmacy Formulary | ||
| Advantage | Advantage | |
| Retail Pharmacy Customer Share | ||
| In-Network | Retail (per 30-day supply): Generic: You pay $5 Preferred Brand: You pay $30 Non-Preferred Brand: You pay $50 | Retail (per 30-day supply): Generic: You pay $5 Preferred Brand: You pay $30 Non-Preferred Brand: You pay $50 |
| Out-Of-Network | 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 20% up to a maximum of $150 Retail and Home Delivery (per 90-day supply): Generic: You pay $15 Preferred Brand: You pay $90 Non-Preferred Brand: You pay $150 | Retail and Home Delivery (per 30-day supply): Specialty: You pay 20% up to a maximum of $150 Retail and Home Delivery (per 90-day supply): Generic: You pay $15 Preferred Brand: You pay $90 Non-Preferred Brand: You pay $150 |
| Out-Of-Network | Not Covered for all benefits | Not Covered for all benefits |
Plan Coinsurance
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 70% |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 70% |
Individual Deductible
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Individual - Employee Only: $1,700 Individual - within a Family: $3,400 |
| Out-of-Network | Individual - Employee Only: $3,000 Individual - within a Family: $5,600 |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Individual: $500 |
| Out-of-Network | Individual: $1,000 |
Family Deductible
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Family Maximum: $3,400 |
| Out-of-Network | Family Maximum: $6,000 |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Family: $1,000 |
| Out-of-Network | Family: $2,000 |
Individual Out-of-Pocket
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Individual - Employee Only: $3,000 Individual - within a Family: $3,400 |
| Out-of-Network | Individual - Employee Only: $6,000 Individual - within a Family: $6,000 |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Individual: $2,500 |
| Out-of-Network | Individual: $5,000 |
Family Out-of-Pocket
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Family Maximum: $6,000 |
| Out-of-Network | Family Maximum: $12,000 |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Family: $5,000 |
| Out-of-Network | Family: $10,000 |
Primary Care Office Visit
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 70% |
| Open Access Plus - OAP | |
|---|---|
| In-Network | $20 copay, and plan pays 100% |
| Out-of-Network | Plan pays 70% |
Specialist Care Office Visit
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 70% |
| Open Access Plus - OAP | |
|---|---|
| In-Network | $25 copay, and plan pays 100% |
| Out-of-Network | Plan pays 70% |
Emergency Room
| Open Access Plus - HDHPQ OAP | |
|---|---|
| Plan pays 90% |
| Open Access Plus - OAP | |
|---|---|
| $100 copay, and plan pays 100% |
Urgent Care
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 70% |
| Open Access Plus - OAP | |
|---|---|
| In-Network | $40 copay, and plan pays 100% |
| Out-of-Network | Plan pays 70% |
Outpatient Radiology
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 70% |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 70% |
Independent Laboratory
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 70% |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 70% |
Outpatient Physical, Speech, Hearing, and Occupational Therapy
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 70% |
| Open Access Plus - OAP | |
|---|---|
| In-Network | $25 copay, and plan pays 100% |
| Out-of-Network | Plan pays 70% |
Pharmacy Formulary
| Open Access Plus - HDHPQ OAP | |
|---|---|
| Advantage |
| Open Access Plus - OAP | |
|---|---|
| Advantage |
Retail Pharmacy Customer Share
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $5 Preferred Brand: You pay $30 Non-Preferred Brand: You pay $50 |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $5 Preferred Brand: You pay $30 Non-Preferred Brand: You pay $50 |
Home Delivery Pharmacy Customer Share
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay 20% up to a maximum of $150 Retail and Home Delivery (per 90-day supply): Generic: You pay $15 Preferred Brand: You pay $90 Non-Preferred Brand: You pay $150 |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay 20% up to a maximum of $150 Retail and Home Delivery (per 90-day supply): Generic: You pay $15 Preferred Brand: You pay $90 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 # 00621855
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 | |
|---|---|---|
| Plan Coinsurance | ||
| In-Network | Plan pays 90% | Plan pays 90% |
| Out-Of-Network | Plan pays 70% | Plan pays 70% |
| Individual Deductible | ||
| In-Network | Individual - Employee Only: $1,700 Individual - within a Family: $3,400 | Individual: $500 |
| Out-Of-Network | Individual - Employee Only: $3,000 Individual - within a Family: $5,600 | Individual: $1,000 |
| Family Deductible | ||
| In-Network | Family Maximum: $3,400 | Family: $1,000 |
| Out-Of-Network | Family Maximum: $6,000 | Family: $2,000 |
| Individual Out-of-Pocket | ||
| In-Network | Individual - Employee Only: $3,000 Individual - within a Family: $3,400 | Individual: $2,500 |
| Out-Of-Network | Individual - Employee Only: $6,000 Individual - within a Family: $6,000 | Individual: $5,000 |
| Family Out-of-Pocket | ||
| In-Network | Family Maximum: $6,000 | Family: $5,000 |
| Out-Of-Network | Family Maximum: $12,000 | Family: $10,000 |
| Primary Care Office Visit | ||
| In-Network | Plan pays 90% | $20 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 70% | Plan pays 70% |
| Specialist Care Office Visit | ||
| In-Network | Plan pays 90% | $25 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 70% | Plan pays 70% |
| Emergency Room | ||
| Plan pays 90% | $100 copay, and plan pays 100% | |
| Urgent Care | ||
| In-Network | Plan pays 90% | $40 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 70% | Plan pays 70% |
| Outpatient Radiology | ||
| In-Network | Plan pays 90% | Plan pays 90% |
| Out-Of-Network | Plan pays 70% | Plan pays 70% |
| Independent Laboratory | ||
| In-Network | Plan pays 90% | Plan pays 90% |
| Out-Of-Network | Plan pays 70% | Plan pays 70% |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | ||
| In-Network | Plan pays 90% | $25 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 70% | Plan pays 70% |
| Pharmacy Formulary | ||
| Advantage | Advantage | |
| Retail Pharmacy Customer Share | ||
| In-Network | Retail (per 30-day supply): Generic: You pay $5 Preferred Brand: You pay $30 Non-Preferred Brand: You pay $50 | Retail (per 30-day supply): Generic: You pay $5 Preferred Brand: You pay $30 Non-Preferred Brand: You pay $50 |
| Out-Of-Network | 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 20% up to a maximum of $150 Retail and Home Delivery (per 90-day supply): Generic: You pay $15 Preferred Brand: You pay $90 Non-Preferred Brand: You pay $150 | Retail and Home Delivery (per 30-day supply): Specialty: You pay 20% up to a maximum of $150 Retail and Home Delivery (per 90-day supply): Generic: You pay $15 Preferred Brand: You pay $90 Non-Preferred Brand: You pay $150 |
| Out-Of-Network | Not Covered for all benefits | Not Covered for all benefits |
Plan Coinsurance
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 70% |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 70% |
Individual Deductible
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Individual - Employee Only: $1,700 Individual - within a Family: $3,400 |
| Out-of-Network | Individual - Employee Only: $3,000 Individual - within a Family: $5,600 |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Individual: $500 |
| Out-of-Network | Individual: $1,000 |
Family Deductible
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Family Maximum: $3,400 |
| Out-of-Network | Family Maximum: $6,000 |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Family: $1,000 |
| Out-of-Network | Family: $2,000 |
Individual Out-of-Pocket
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Individual - Employee Only: $3,000 Individual - within a Family: $3,400 |
| Out-of-Network | Individual - Employee Only: $6,000 Individual - within a Family: $6,000 |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Individual: $2,500 |
| Out-of-Network | Individual: $5,000 |
Family Out-of-Pocket
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Family Maximum: $6,000 |
| Out-of-Network | Family Maximum: $12,000 |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Family: $5,000 |
| Out-of-Network | Family: $10,000 |
Primary Care Office Visit
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 70% |
| Open Access Plus - OAP | |
|---|---|
| In-Network | $20 copay, and plan pays 100% |
| Out-of-Network | Plan pays 70% |
Specialist Care Office Visit
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 70% |
| Open Access Plus - OAP | |
|---|---|
| In-Network | $25 copay, and plan pays 100% |
| Out-of-Network | Plan pays 70% |
Emergency Room
| Open Access Plus - HDHPQ OAP | |
|---|---|
| Plan pays 90% |
| Open Access Plus - OAP | |
|---|---|
| $100 copay, and plan pays 100% |
Urgent Care
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 70% |
| Open Access Plus - OAP | |
|---|---|
| In-Network | $40 copay, and plan pays 100% |
| Out-of-Network | Plan pays 70% |
Outpatient Radiology
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 70% |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 70% |
Independent Laboratory
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 70% |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 70% |
Outpatient Physical, Speech, Hearing, and Occupational Therapy
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 70% |
| Open Access Plus - OAP | |
|---|---|
| In-Network | $25 copay, and plan pays 100% |
| Out-of-Network | Plan pays 70% |
Pharmacy Formulary
| Open Access Plus - HDHPQ OAP | |
|---|---|
| Advantage |
| Open Access Plus - OAP | |
|---|---|
| Advantage |
Retail Pharmacy Customer Share
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $5 Preferred Brand: You pay $30 Non-Preferred Brand: You pay $50 |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $5 Preferred Brand: You pay $30 Non-Preferred Brand: You pay $50 |
Home Delivery Pharmacy Customer Share
| Open Access Plus - HDHPQ OAP | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay 20% up to a maximum of $150 Retail and Home Delivery (per 90-day supply): Generic: You pay $15 Preferred Brand: You pay $90 Non-Preferred Brand: You pay $150 |
| Open Access Plus - OAP | |
|---|---|
| In-Network | Retail and Home Delivery (per 30-day supply): Specialty: You pay 20% up to a maximum of $150 Retail and Home Delivery (per 90-day supply): Generic: You pay $15 Preferred Brand: You pay $90 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.