Page 6 - Rampart EE Guide 01-19 (flipbook)

BENEFITS

MEDICAL INSURANCE

Cigna
Plan Name OAP with HRA
Network Name Cigna Open Access Plus Non-Network
Health Benefits
Lifetime Maximum Benefit Unlimited

Deductible (Annual)
- Individual $2,000 $5,000
- Family $4,000 $10,000
Co-Insurance (Plan Pays) 100% 60%
Office Visit Copay
- Primary Care Physician Deductible, 100% Deductible, 60%
- Specialist Office Visit Deductible, 100% Deductible, 60%
- Telehealth Deductible, 100% Not Covered
Out-of-Pocket Maximum
- Individual $2,000 $7,500
- Family $4,000 $15,000

Hospitalization
- Inpatient Deductible, 100% $500/Admit, Deductible, 60%
- Outpatient Deductible, 100% $500/Admit, Deductible, 60%
Lab and X-Ray Deductible, 100% Deductible, 60%
Emergency Services Deductible, 100%
Urgent Care Deductible, 100% Deductible, 60%

Preventive Care 100% (Deductible Waived) Deductible, 60%
Chiropractic Deductible, 100% Deductible, 60%
Max 20 Visits/Year
Pharmacy Benefits

Pharmacy Deductible
- Individual $0 $0
- Family $0 $0
Retail Pharmacy
- Tier 1 $10 Copay 50% Reimbursement
- Tier 2 $25 Copay 50% Reimbursement
- Tier 3 $50 Copay 50% Reimbursement
- Supply Limit 30 Days 30 Days

Mail Order Pharmacy
- Tier 1 $20 Copay Not Covered
- Tier 2 $50 Copay Not Covered
- Tier 3 $100 Copay Not Covered
- Supply Limit 90 Days N/A

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