Plan Details
Plan Name	Cigna OAP 2000 Base
Effective Dates	Jan 01, 2025 to Jan 01, 2026
Benefits	In-Network	Out-of-Network
Annual Deductible/Individual	$2,000	$4,000
Annual Deductible/Family	$4,000	$8,000
Coinsurance	30%	50%
Office Visit/Exam	$30 copay/visit	50% after deductible
Outpatient Specialist Visit	$50 copay/visit	50% after deductible
Annual Out-of-Pocket Limit/Individual	$5,000	$10,000
Annual Out-of-Pocket Limit/Family	$10,000	$20,000
Preventive Care	0%	50% after dedcutible
Inpatient Hospitalization	30% after deductible	50% after dedcutible
Surgical Services Outpatient Facility Charge	30% after deductible	50% after deductible
Emergency Room	$250	$250
Urgent Care Facility	$50 copay/visit, deductible doesn't apply	50% after dedcutible
Prescription Drug Deductible	-	-
Prescription Drugs - Generic	$10 (retail)	Not Covered
Prescription Drugs - Brand (Formulary/Preferred)	$30 (retail) after drug deductible	Not Covered
Prescription Drugs - Brand (Non-Formulary/Non-preferred)	$55 (retail)after drug deductible	Not Covered
Prescription Drugs - Specialty	30% $250 maximum copay; after drug deductible	Not Covered
Chiropractic Services	$50 copay, limited to 20 visits per year	50% after deductible, limited to 20 visits per year
Acupuncture	$30 up to 20 visits/year	50% after deductible, limited to 20 visits per year