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MEDICAL INSURANCE

Cigna
Plan Features Option 2 OAP PPO
Open Access Plus
Network Name (OAP) Non-Network
HEALTH BENEFITS You Pay You Pay
Lifetime Maximum Unlimited
Annual Deductible
Individual $750
Individual in a Family $750
Family $1,500
Coinsurance 80% 60%
Physician Office Visit Ded Waived
Primary Care Physician $25 Copay 40%
Specialist $40 Copay 40%
Out-of-Pocket Maximum
Individual $3,500
Family $7,000
Hospitalization
Inpatient 20% $500 Copay, 40%
Outpatient Surgery 20% 40%
Emergency Services Ded Waived, $150 Copay
Urgent Care Ded Waived, 40%
$35 Copay
Acupuncture $25 Copay 40%
12 Visits/Year
Preventive Care Ded Waived, 0% 40%
Mental Disorders and Substance
Abuse
Inpatient 20% $500 Copay, 40%
Outpatient Ded Waived, 40%
$25 Copay
PHARMACY BENEFITS You Pay You Pay
Pharmacy Deductible None

Retail (30 Day Supply)
Generic Formulary $10 Copay Not Covered
Brand Name Formulary $25 Copay Not Covered
Non-Formulary $50 Copay Not Covered
Mail Order (90 Day Supply)
Generic Formulary $20 Copay Not Covered
Brand Name Formulary $50 Copay Not Covered
Non-Formulary $100 Copay Not Covered

Specialty (30 Day Supply) 20% Max $250 Not Covered

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