Page 3 - VSolvit 2021 Benefits Brochure
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VSolvit
    2021 Employee Benefits Brochure




        Medical Plans – Cigna Open Access Plus (OAP) Plans




                                              High Deductible         In‐Network Only           Low Deductible
                                               OAP H.S.A.*                   OAP                     OAP*


         Deductible:
         Individual Family                         $2,600                   $450                      $100
                                                   $5,200                   $700                      $200


         Annual Out of Pocket
         Maximum: Individual
         Family                                    $4,000                    $2,800                  $1,500
                                                   $8,000                    $5,300                  $3,000


         Hospital Services:
         Inpatient Outpatient               20% after deductible      20% after deductible    10% after deductible

         Surgery Emergency Room             20% after deductible      20% after $250 copay    10% after deductible

                                            20% after deductible        $150 copay after      10% after $150 copay
                                                                           deductible


         Physician Services:
         Office Visit (PCP/Specialist)      20% after deductible     $15 copay / $30 copay    $20 copay / $20 copay

         Urgent Care                        20% after deductible           $35 copay               $35 copay



         Preventive Care:                        No charge                 No Charge               No charge



         Prescription Drugs:                   Combined with
         Rx Deductible                        medical deductible             None                     None

         Tier 1 ‐ (30/90‐day supply)              $10 / $20                $10 / $20                $10 / $20
         Tier 2 ‐ (30/90‐day supply)              $40 / $80                $30 / $60                $40 / $80
         Tier 3 ‐ (30/90‐day supply)             $60 / $120                $50 / $100              $60 / $120
         Specialty ‐ (30‐day supply)           $20 / $80 / $120         $20 / $60 / $100         $20 / $80 / $120


        *The table above shows ‘in‐network’ costs only. Please refer to carrier benefit summaries for more detailed information &
        out‐of‐network benefits


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