Page 6 - Rampart EE Guide 01-20.pub

BENEFITS

MEDICAL INSURANCE

Cigna
Plan Name OAP with HRA
Network Name Cigna Open Access Plus Non‐Network
Health Benefits
Life me Maximum Benefit Unlimited

Deduc ble (Annual)
‐ Individual $2,000 $5,000
‐ Family $4,000 $10,000
Co‐Insurance (Plan Pays) 100% 60%
Office Visit Copay
‐ Primary Care Physician Deduc ble, 100% Deduc ble, 60%
‐ Specialist Office Visit Deduc ble, 100% Deduc ble, 60%

‐ Telehealth (copay applied to deducƟble, then
100% coverage) Not Covered
AmWell $49
MD Live $45
Out‐of‐Pocket Maximum
‐ Individual $2,000 $7,500
‐ Family $4,000 $15,000

Hospitaliza on
‐ Inpa ent Deduc ble, 100% $500/Admit, Deduc ble, 60%
‐ Outpa ent Deduc ble, 100% $500/Admit, Deduc ble, 60%
Lab and X‐Ray Deduc ble, 100% Deduc ble, 60%
Emergency Services Deduc ble, 100%

Urgent Care Deduc ble, 100% Deduc ble, 60%
Preven ve Care 100% (Deduc ble Waived) Deduc ble, 60%
Chiroprac c Deduc ble, 100% Deduc ble, 60%
Max 20 Visits/Year
Pharmacy Benefits

Pharmacy Deduc ble
‐ 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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