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Plan Name Open Access Plus HDHPQ Open Access Plus PlanIn Network BenefitsDeductible(Employee / Family)$1,750 / $3,500(no more than $3,300 per individualwithin a family)$600 / $1,200Coinsurance(Member Pays)0% 20%Maximum Out of Pocket Cost (MOOP)(Employee / Family)$1,750 / $3,500(no more than $3,300 per individualwithin a family)$1,200 / $2,400Primary Care Provider (PCP) 15% After Deductible $25 CopayWellness & Preventative Covered at 100% Covered at 100%Specialist 15% After Deductible $40 CopayInpatient Hospitalization 15% After Deductible 20% After DeductibleOutpatient Facility 15% After Deductible 20% After DeductibleEmergency Room 15% After Deductible 20% After DeductibleUrgent Care 15% After Deductible 20% After DeductibleLaboratory 15% After Deductible 20% After DeductibleX-Ray 15% After Deductible 20% After DeductibleImaging (CT, MRI, PET) 15% After Deductible 20% After DeductibleBenefit Period Calendar Year Calendar YearGatekeeper Non-gated Non-gatedOut-of-Network BenefitsDeductible(Employee / Family)$1,650 / $3,300(no more than $3,300 per individualwithin a family)$1,200 / $2,400Coinsurance(Member Pays)50% 50%Maximum Out-of-Pocket Cost (MOOP)(Employee / Family)$6,000 / $12,000(no more than $6,000 per individualwithin a family)$6,400 / $12,800Prescription BenefitsGeneric / Preferred / Non-Preferred $15 copay / $35 copay / $75 copay $10 copay / $50 copay / $60 copayMedical Plans & Prescription BenefitsArdena offers two Cigna medical plans with prescription benefits: a Low Plan and aHigh Plan. Both plans cover wellness and preventive care at 100%.Low Plan High Plan8