Page 9 - Demo

Plan Name OAPIN Buyup OAP-Open Access Plus PlanIn Network BenefitsDeductible(Employee / Family)$0 / $0 $1,000 / $3,750Coinsurance(Member Pays)0% 10%Maximum Out of Pocket Cost (MOOP)(Employee / Family)$3,500 / $8,750(no more than $3,300 per individualwithin a family)$4,000 / $10,000Primary Care Provider (PCP) $35 Copay $25 CopayWellness & Preventative Covered at 100% Covered at 100%Specialist $60 Copay $40 CopayInpatient Hospitalization $1,000 copay 10% After DeductibleOutpatient Facility $300 copay per visit 10% After DeductibleEmergency Room $400 copay (waived if admitted) $400 copay (waived if admitted)Urgent Care $75 copay $75 copayLaboratory No Charge 10% After DeductibleX-Ray No Charge 10% After DeductibleImaging (CT, MRI, PET) $75 copay 10% After DeductibleBenefit Period Calendar Year Calendar YearGatekeeper Non-gated Non-gatedOut-of-Network BenefitsDeductible(Employee / Family)Not Covered$2,000 / $5,000Coinsurance(Member Pays)30%Maximum Out-of-Pocket Cost (MOOP)(Employee / Family)$5,000 / $12,500Prescription BenefitsGeneric / Preferred / Non-Preferred$15 copay / $35 copay / $55 copay $15 copay / $30 copay / $60 copayMedical Plans & Prescription BenefitsMancini Duffy offers Four Cigna medical plans with prescription benefits: All planscover wellness and preventive care at 100%.Plan 3 Plan 49