Page 8 - Guide
P. 8
2017 Benefits Enrollment
OAP Plan Choice Fund HSA Plan
In-Network Out-of-Network In-Network Out-of-Network
Plan Maximum
Per lifetime Unlimited Unlimited
Deductible per Calendar Year
Per individual $1,100 $2,200 $2,500 $5,000
Per family $2,750 $5,500 $5,000 $10,000
Maximum Out-of-Pocket Exposure per Calendar Year (Includes Deductible)
Per individual $3,000 $10,000 $3,500 $14,000
Per family $7,500 $25,000 $6,850 $28,000
Coinsurance 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Covered Services
Hospital Services
Inpatient 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Outpatient 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Emergency room 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Urgent care center 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Physician Services
Ofice visit PCP—$25 copay 60% after deductible 80% after deductible 60% after deductible
Specialist—$50 copay
Other Covered Services
Preventive care 100% covered 60% after deductible 100% covered 60% after deductible
Prescription Drug Benefit*
OAP Plan Choice Fund HSA Plan
Retail Pharmacy Mail Order Pharmacy Retail Pharmacy Mail Order Pharmacy
Generic $8 copay $16 copay 80% after deductible
Preferred brands $40 copay $80 copay HSA preventive generic drug list—100%
Non-preferred brands $70 copay $140 copay covered
Listed no cost preventive medications 100% 100%
* All specialty medications must be illed through the CIGNA Specialty Pharmacy network; if you select a brand name drug when a generic
equivalent is available, the plan will only pay the cost of the generic drug; the plan will not cover medications for which there is an equivalent
over-the-counter alternative.
Bi-Weekly Medical Contributions—Paid By You on a Pre-Tax Basis
With Tobacco With Wellness With Wellness and Tobacco
Employee Premiums Surcharge Surcharge Surcharge
OAP Plan Bi-weekly Rates
Employee Only $21.23 $67.38 $52.00 $98.15
Employee + Spouse $96.13 $142.28 $126.90 $173.05
Employee + Child(ren) $61.80 $107.95 $92.57 $138.72
Family $142.59 $188.74 $173.36 $219.51
HSA Plan Bi-weekly Rates
Employee Only $13.27 $59.42 $44.04 $90.19
Employee + Spouse $62.85 $109.00 $93.62 $139.77
Employee + Child(ren) $49.76 $95.91 $80.53 $126.68
Family $95.77 $141.92 $126.54 $172.69
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OAP Plan Choice Fund HSA Plan
In-Network Out-of-Network In-Network Out-of-Network
Plan Maximum
Per lifetime Unlimited Unlimited
Deductible per Calendar Year
Per individual $1,100 $2,200 $2,500 $5,000
Per family $2,750 $5,500 $5,000 $10,000
Maximum Out-of-Pocket Exposure per Calendar Year (Includes Deductible)
Per individual $3,000 $10,000 $3,500 $14,000
Per family $7,500 $25,000 $6,850 $28,000
Coinsurance 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Covered Services
Hospital Services
Inpatient 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Outpatient 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Emergency room 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Urgent care center 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Physician Services
Ofice visit PCP—$25 copay 60% after deductible 80% after deductible 60% after deductible
Specialist—$50 copay
Other Covered Services
Preventive care 100% covered 60% after deductible 100% covered 60% after deductible
Prescription Drug Benefit*
OAP Plan Choice Fund HSA Plan
Retail Pharmacy Mail Order Pharmacy Retail Pharmacy Mail Order Pharmacy
Generic $8 copay $16 copay 80% after deductible
Preferred brands $40 copay $80 copay HSA preventive generic drug list—100%
Non-preferred brands $70 copay $140 copay covered
Listed no cost preventive medications 100% 100%
* All specialty medications must be illed through the CIGNA Specialty Pharmacy network; if you select a brand name drug when a generic
equivalent is available, the plan will only pay the cost of the generic drug; the plan will not cover medications for which there is an equivalent
over-the-counter alternative.
Bi-Weekly Medical Contributions—Paid By You on a Pre-Tax Basis
With Tobacco With Wellness With Wellness and Tobacco
Employee Premiums Surcharge Surcharge Surcharge
OAP Plan Bi-weekly Rates
Employee Only $21.23 $67.38 $52.00 $98.15
Employee + Spouse $96.13 $142.28 $126.90 $173.05
Employee + Child(ren) $61.80 $107.95 $92.57 $138.72
Family $142.59 $188.74 $173.36 $219.51
HSA Plan Bi-weekly Rates
Employee Only $13.27 $59.42 $44.04 $90.19
Employee + Spouse $62.85 $109.00 $93.62 $139.77
Employee + Child(ren) $49.76 $95.91 $80.53 $126.68
Family $95.77 $141.92 $126.54 $172.69
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