Page 54 - Benefits Summary 2018-2019

General Services In-Network Out-of-Network
Out-of-pocket annual maximum
 Medical copays apply towards the out-of-pocket
maximums
 Medical deductibles apply towards the out-of- Individual: $6,000 Individual: $12,000
pocket maximums Individual – In a Family:
 Expenses do not cross accumulate between in- Individual – In a Family: $6,000 $12,000
Family: $12,000
network and out-of-network out-of-pocket Family: $24,000
maximums
 This plan includes a combined
Medical/Pharmacy out-of-pocket maximum.
Unlimited
Lifetime maximum
Per individual
Unlimited
Out-of-network annual maximum
Per individual
Emergency room care After the plan deductible is met,
 All services rendered apply to ER benefit You pay 0%
including Lab & X-ray Plan pays 100%
After the in-network plan deductible is met,
Ambulance You pay 0%
Plan pays 100%
After the plan deductible is met, After the plan deductible is met,
Office surgery – PCP/Specialist You pay 0% You pay 30%
Plan pays 100% Plan pays 70%
After the plan deductible is met, Covered same as plan’s
Other office services – laboratory You pay 0% Physician’s Office Services
Plan pays 100%
After the plan deductible is met,
Covered same as plan’s
Other office services – radiology You pay 0% Physician’s Office Services
Plan pays 100%
After the plan deductible is met,
After the plan deductible is met,
Outpatient lab You pay 30%
Plan pays 100%
Plan pays 70%
After the plan deductible is met,
After the plan deductible is met,
Outpatient radiology You pay 30%
Plan pays 100%
Plan pays 70%
After the plan deductible is met,
After the plan deductible is met,
Independent lab You pay 30%
Plan pays 100%
Plan pays 70%
Office advanced radiology imaging services After the plan deductible is met, After the plan deductible is met,
 Includes MRI, MRA, PET, CT-Scan and You pay 0% You pay 30%
Nuclear medicine Plan pays 100% Plan pays 70%
Outpatient advanced radiology imaging services After the plan deductible is met, After the plan deductible is met,
 Includes MRI, MRA, PET, CT-Scan and You pay 0% You pay 30%
Nuclear medicine Plan pays 100% Plan pays 70%
Durable medical equipment After the plan deductible is met, After the plan deductible is met,
 Includes external prosthetic appliances You pay 0% You pay 30%
 Does accumulate towards the out-of-pocket Plan pays 100% Plan pays 70%
maximum
Breast Feeding Equipment and Supplies Plan pays 100%, After the plan deductible is met,
 Limited to the rental of one breast pump per no copay, You pay 30%
birth as ordered or prescribed by a physician. no deductible Plan pays 70%
Includes related supplies

11/1/2018
ASO
Health Savings Account Open Access Plus - HSA OAP 11-2018 - 7900133. Version# 12

2 of 8 ©Cigna 2018