Page 33 - Benefits Summary 2018-2019

Benefits In-Network Out-of-Network
Abortion Varies based on place of Varies based on place of
 Includes non-elective procedures service service
 Includes elective procedures in-network only
After the plan deductible is met,
Varies based on place of
TMJ You pay 30%
service
Plan pays 70%
Organ transplant
 Services paid at network level if performed at
Cigna LifeSOURCE Transplant Network®
Facilities You pay $300 per admission
 Travel maximum $10,000 per transplant (only deductible,
available if using Cigna LifeSOURCE Then Not Covered
Transplant Network® facility) Plan pays 100%
 $300 in-network per admission deductible is
separate and in addition to the plan deductible.
Plan deductible only applies to the Professional
Services.
Out-of-area services
 Coverage for services rendered outside a
network area
 ER and Ambulance paid the same as network For all other services
You pay 20%
services
Plan pays 80%
 Preventive care services covered at 100% for after the out of network deductible is met
out of area
 Out-of-network deductible and out-of-pocket
maximums apply
Pharmacy In-Network Out-of-Network
Cost Share and Supply
Pharmacy Cost Share Retail (per 30-day supply): Retail:
 Retail – up to 90-day supply Generic: You pay $10 You pay 50%
(except Specialty up to 30-day supply) Preferred Brand: You pay $35 Your plan pays 50%
 Home Delivery – up to 90-day supply Non-Preferred Brand: You pay
(except Specialty up to 30-day supply) $70 Home Delivery:
 If you receive a supply of 34 days or less at Not Covered
home delivery (including a Specialty Retail (per 90-day supply):
Prescription Drug), the home delivery pharmacy Generic: You pay $30
cost share will be adjusted to reflect a 30-day Preferred Brand: You pay $105
supply. Non-Preferred Brand: You pay
$210

Home Delivery (per 90-day
supply):
Generic: You pay $25
Preferred Brand: You pay $88
Non-Preferred Brand: You pay
$175

11/1/2018
ASO
Open Access Plus - OAP High 11-2018 - 7899546. Version# 12

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