Page 5 - AB Mauri 2022 Benefits Guide OHLY

2022 Benefits Enrollment
Cigna Medical and Prescription Plans

OAP High Deductible Health Plan/HSA
Calendar Year Deductible (Embedded)
Individual $500 $3,000
Family $1,000 $6,000
Out-of-Pocket Maximum

Individual $1,500 $6,000
Family $3,000 $12,000
Hospital Services
Inpatient 10% after deductible 100% covered after deductible
Outpatient 10% after deductible 100% covered after deductible
Emergency Room 10% after deductible 100% covered after deductible
Oice Visits
Preventive Care 100% covered 100% covered
10% after deductible 100% covered after deductible
Virtual Visit
visit cost $55 visit cost $55
Primary Care 10% after deductible 100% covered after deductible
Specialist 10% after deductible 100% covered after deductible

Chiropractic Care 10% after deductible 100% covered after deductible
Urgent Care 10% after deductible 100% covered after deductible
Prescription Drugs
Retail—30 Day Supply Preventive Rx 100% covered
Tier 1 $15 copay $10 copay after deductible
Tier 2 $30 copay $30 copay after deductible
Tier 3 $50 copay $60 copay after deductible

Mail Order—90 Day Supply
Tier 1 $30 copay $30 copay after deductible
Tier 2 $60 copay $90 copay after deductible
Tier 3 $100 copay $180 copay after deductible

Please note: The above chart is a summary of the medical plan beneits for in-network coverage. The OAP and HDHP ofers out-of-network beneits;
however, beneits are reduced when care is provided out-of-network. The chart above is a brief summary of your medical beneits and does not
include all the details about beneit plan features and rules. For details and the terms of your medical and pharmacy plan beneits, refer to your Plan
document. If there are any inconsistencies between this document and the oicial Plan document, the Plan documents or certiicates of insurance
will prevail.
The preventive Rx list for the HDHP/HSA plan can be obtained from Human Resources.

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