Your Medical Benefits
Open Access Plus - HDHPQ OAP
Benefit Summary
Group # 00621855
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.
A HDHP, or High Deductible Health Plan, can be combined with a tax-advantaged saving account allowing you to pay for certain medical expenses with money free from federal taxes. Until you reach your deductible, you must pay for most of your health care expenses out-of-pocket.
Note: The Plan deductible always applies before any benefit copay/deductible or coinsurance.
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Plan Documents
| In-Network | Out-of-Network | |
|---|---|---|
| Plan Name | Open Access Plus - HDHPQ OAP | |
| Plan Coinsurance | Plan pays 90% | Plan pays 70% |
| Individual Deductible | Individual - Employee Only: $1,700 Individual - within a Family: $3,400 | Individual - Employee Only: $3,000 Individual - within a Family: $5,600 |
| Family Deductible | Family Maximum: $3,400 | Family Maximum: $6,000 |
| Individual Out-of-Pocket | Individual - Employee Only: $3,000 Individual - within a Family: $3,400 | Individual - Employee Only: $6,000 Individual - within a Family: $6,000 |
| Family Out-of-Pocket | Family Maximum: $6,000 | Family Maximum: $12,000 |
| Primary Care Office Visit | Plan pays 90% | Plan pays 70% |
| Specialist Care Office Visit | Plan pays 90% | Plan pays 70% |
| Emergency Room | Plan pays 90% | |
| Urgent Care | Plan pays 90% | Plan pays 70% |
| Outpatient Radiology | Plan pays 90% | Plan pays 70% |
| Independent Laboratory | Plan pays 90% | Plan pays 70% |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | Plan pays 90% | Plan pays 70% |
| Pharmacy Formulary | Advantage | |
| Retail Pharmacy Customer Share | Retail (per 30-day supply): Generic: You pay $5 Preferred Brand: You pay $30 Non-Preferred Brand: You pay $50 | Not Covered for all benefits |
| Home Delivery Pharmacy Customer Share | 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 | Not Covered for all benefits |
All plans have exclusions and limitations. For a summary of these exclusions and limitations, view the Summary of Benefits and Coverage.
Benefit Summary
Group # 00621855
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.
A HDHP, or High Deductible Health Plan, can be combined with a tax-advantaged saving account allowing you to pay for certain medical expenses with money free from federal taxes. Until you reach your deductible, you must pay for most of your health care expenses out-of-pocket.
Note: The Plan deductible always applies before any benefit copay/deductible or coinsurance.
| In-Network | Out-of-Network | |
|---|---|---|
| Plan Name | Open Access Plus - HDHPQ OAP | |
| Plan Coinsurance | Plan pays 90% | Plan pays 70% |
| Individual Deductible | Individual - Employee Only: $1,700 Individual - within a Family: $3,400 | Individual - Employee Only: $3,000 Individual - within a Family: $5,600 |
| Family Deductible | Family Maximum: $3,400 | Family Maximum: $6,000 |
| Individual Out-of-Pocket | Individual - Employee Only: $3,000 Individual - within a Family: $3,400 | Individual - Employee Only: $6,000 Individual - within a Family: $6,000 |
| Family Out-of-Pocket | Family Maximum: $6,000 | Family Maximum: $12,000 |
| Primary Care Office Visit | Plan pays 90% | Plan pays 70% |
| Specialist Care Office Visit | Plan pays 90% | Plan pays 70% |
| Emergency Room | Plan pays 90% | |
| Urgent Care | Plan pays 90% | Plan pays 70% |
| Outpatient Radiology | Plan pays 90% | Plan pays 70% |
| Independent Laboratory | Plan pays 90% | Plan pays 70% |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | Plan pays 90% | Plan pays 70% |
| Pharmacy Formulary | Advantage | |
| Retail Pharmacy Customer Share | Retail (per 30-day supply): Generic: You pay $5 Preferred Brand: You pay $30 Non-Preferred Brand: You pay $50 | Not Covered for all benefits |
| Home Delivery Pharmacy Customer Share | 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 | Not Covered for all benefits |
All plans have exclusions and limitations. For a summary of these exclusions and limitations, view the Summary of Benefits and Coverage.