Plan Details
Plan Name	Cigna OAP 500 Buy Up
Effective Dates	Jan 01, 2025 to Jan 01, 2026
Benefits	In-Network	Out-of-Network
Annual Deductible/Individual	$500	$5,000
Annual Deductible/Family	$1,000	$10,000
Coinsurance	0%	50%
Office Visit/Exam	$30 copay/visit	50% after dedcutible
Outpatient Specialist Visit	$40 copay/visit	50% after dedcutible
Annual Out-of-Pocket Limit/Individual	$4,000	$10,000
Annual Out-of-Pocket Limit/Family	$8,000	$20,000
Preventive Care	0%	50% after deductible
Inpatient Hospitalization	$750 copay/day first 3 days per stay; 0% thereafter; after deductible	50% after deductible
Surgical Services Outpatient Facility Charge	$750 copay/visit	50% after deductible
Emergency Room	$250 copay/visit; after deductible	$250 copay/visit; after deductible
Urgent Care Facility	$50 copay/visit	50% after dedcutible
Prescription Drug Deductible	$0	$0
Prescription Drugs - Generic	$10 (retail)	Not Covered
Prescription Drugs - Brand (Formulary/Preferred)	$30 (retail)	Not Covered
Prescription Drugs - Brand (Non-Formulary/Non-preferred)	$50 (retail)	Not Covered
Prescription Drugs - Specialty	30% ; $250 maximum copay	Not Covered
Chiropractic Services	$40 copay, limited to 20 visits per year	50% after deductible, limited to 20 visits per year
Acupuncture	$30 20 visits/year	50% after deductible