ENGLISH
Resources



Cigna Group Number: 123

Cigna Customer Service
(866) 494-2111
Available 24/7



Downloads:

 OAP Core Plan - Benefit Summary

 OAP Buy Up Plan - Benefit Summary

 OAP Core Plan - Summary of Benefits & Coverage

 OAP Buy Up Plan - Summary of Benefits & Coverage






ESPANOL
Recursos



Cigna Group Number: 123456

Cigna Customer Service
(866) 494-2111
Available 24/7



Descargas:

 OAP Plan Bajo - Resumen de Beneficios

 OAP Plan Alto - Resumen de Beneficios

 OAP Plan Bajo - Resumen de Beneficios y Covertura

 OAP Plan Alto - Resumen de Beneficios y Covertura 




 
 
 

                                         Medical Benefits Summary

                                                                                  Provided by Cigna

  Core Plan

Buy Up Plan
Network



Primary Physician  Office Visit
Open Access Plus (OAP)


In-Network: $25 Copay
Out-of-Network: 40% after Deductible
 
Open Access Plus (OAP)



In-Network: $20 Copay
Out-of-Network: 40% after Deductible

 
Specialist Office Visit In-Network: $50 Copay
Out-of-Network: 40% after Deductible

In-Network: $40 Copay
Out-of-Network: 40% after Deductible

 
Urgent Care In-Network: $55 Copay
Out-of-Network: 40% after Deductible

In-Network: $45 Copay
Out-of-Network: 40% after Deductible

 
Emergency Room In-Network: 20% After Deductible
Out-of-Network: 20% After Deductible

In-Network: 20% After Deductible
Out-of-Network: 20% After Deductible

 
Inpatient Care





Ambulatory Surgical Center
In-Network: 20% After Deductible
Out-of-Network: 40% After Deductible


In-Network: 20% After Deductible
Out-of-Network: 40% After Deductible
In-Network: $600 per admission deductible
Out-of-Network: 40% After Deductible


 
In-Network: $200 copay

Out-of-Network: 40% After Deductible

 
Child Wellness In-Network: Covered at 100%
Out-of-Network: 40% After Deductible

In-Network: Covered at 100%
Out-of-Network: 40% after Deductible

 
Adult Routine Physicals In-Network: Covered at 100%
Out-of-Network: 40% After Deductible

In-Network: Covered at 100%
Out-of-Network: 40% after Deductible




Prescription Drug Plan

Prescription Drug Plan


 
  30 Day Supply (Retail)
30 Day Supply (Retail)
 
Tier 1 In-Network: $10
Out-of-Network: 
Member pays 100% at time of purchase, reimbursed 50% after applicable copay
In-Network: $10
Out-of-Network: Member pays 100% at time of purchase, reimbursed 50% after applicable copay
 
Tier 2 In-Network: $50
Out-of-Network: 
Member pays 100% at time of purchase, reimbursed 50% after applicable copay
In-Network: $30
Out-of-Network: Member pays 100% at time of purchase, reimbursed 50% after applicable copay
 
Tier 3







Tier 1





Tier 2





Tier 3
In-Network: $80
Out-of-Network: 
Member pays 100% at time of purchase, reimbursed 50% after applicable copay

Mail Order (90 Day supply)

In-Network: $20

Out-of-Network: 
Member pays 100% at time of purchase, reimbursed 50% after applicable copay

In-Network: $140
Out-of-Network: 
Member pays 100% at time of purchase, reimbursed 50% after applicable copay

In-Network: $230
Out-of-Network: 
Member pays 100% at time of purchase, reimbursed 50% after applicable copay
In-Network: $50
Out-of-Network: Member pays 100% at time of purchase, reimbursed 50% after applicable copay

Mail Order (90 Day Supply)


In-Network: $20
Out-of-Network: 
Member pays 100% at time of purchase, reimbursed 50% after applicable copay

In-Network: $80
Out-of-Network: 
Member pays 100% at time of purchase, reimbursed 50% after applicable copay

In-Network: $140
Out-of-Network: 
Member pays 100% at time of purchase, reimbursed 50% after applicable copay
 
  Calendar Year Deductible Calendar Year Deductible  
Individual In-Network: $1,500
Out-of-Network: $3,000
In-Network: $500
Out-of-Network: $750
 
Family




Member Cost Share
In-Network: $4,500
Out-of-Network
: $9,000

Coinsurance

In-Network: 20% after Deductible
Out-of-Network: 40% after Deductible
In-Network: $1,500
Out-of-Network: $2,250

Coinsurance

In-Network: 20% after Deductible
Out-of-Network: 40% after Deductible
 
  Calendar Year Out-of-Pocket Maximum Calendar Year Out-of-Pocket Maximum  
Individual In-Network: $5,000
Out-of-Network: $8,000
In-Network: $2,500
Out-of-Network: $5,000
 
Family In-Network: $10,000
Out-of-Network: $16,000


Lifetime Maximum Benefit

Unlimited
In-Network: $5,000
Out-of-Network: $10,000

Lifetime Maximum Benefit

Unlimited

  *This site provides a brief summary of your plans; it is not a contract. Please see insurance contracts (available from Human Resources) for complete details and limitations.