Page 4 - VSolvit 2021 EB Brochure_Updated Aug 2021

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 25% after deductible 10% after deductible

Surgery Emergency Room 20% after deductible 25% 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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