MEDICAL INSURANCE
The chart below provides a brief comparison of the available and should not be relied upon to fully determine your coverage. If the below illustration of benefits conflicts in any way with the Summary Plan Description (SPD), the SPD shall prevail. It is recommended that you review your exact description of services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.
JL Marine Systems offers 3 medical plans from Cigna. To find participating providers go to www.cigna.com and click on “Find a Doctor”, choose the appropriate plan type, and click continue. Then, narrow down your search based on location and provider type plans. This chart is intended only to highlight the benefits
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OAP (HSA)
OAPIN 1000
OAP 250
Plan Options:
Micro with Battery Pak
Sportsman
Pro-Series
IN-NETWORK: Plan Year / Contract Year Basis
Calendar Year
Calendar Year
Calendar Year
Deductible (Individual / Family)
$1,500 / $4,500
$1,000 / $3,000
$250 / $750
Maximum Out-of-Pocket (Individual/Family)
$4,500 / $9,000
$4,000 / $8,000
$3,000 / $6,000
Deductible, Coinsurance, & Copays
Deductible, Coinsurance, & Copays
Deductible, Coinsurance, & Copays
Out-of Pocket Max Includes
Lifetime Major Medical Maximum
Unlimited
Unlimited
Unlimited
Coinsurance
80% / 20%
80% / 20%
80% / 20%
Routine Preventive Services
Wellness Immunizations Mammography/Colonoscopy CO-PAYS PCP Required / Open Access
Covered 100%
Covered 100%
Covered 100%
No
No
No
Telemedicine
Deductible & Coinsurance
$25 Copay
$20 Copay
Office Visits/Consultations for Illness/Injury
Deductible & Coinsurance
$25 Copay
$20 copay
Specialist Visits
Deductible & Coinsurance
$45 Copay
$45 copay
Inpatient Hospital
Deductible & Coinsurance Deductible & Coinsurance
Deductible & Coinsurance
Outpatient Surgery
Deductible & Coinsurance Deductible & Coinsurance
Deductible & Coinsurance
Emergency Room
Deductible & Coinsurance
$250 Copay
$200 copay
Urgent Care
Deductible & Coinsurance
$50 Copay
$50 copay
OUTPATIENT DIAGNOSTIC SERVICES Lab Services (Freestanding Lab)
Deductible & Coinsurance
Covered 100%
Covered 100%
X-Ray Services (Freestanding Lab)
Deductible & Coinsurance
Covered 100%
Covered 100%
Complex Diagnostic
Deductible & Coinsurance
$350 Copay
$200 Copay
PRESCRIPTIONS
(After annual deductible)
Retail (30 day supply)
$10 / $50 / $80
$10 / $50 / $80
$10 / $50 / $80
Mail Order (90 day supply)
3 X retail
3 X retail
3 x retail
OUT-OF-NETWORK:
Deductible (Individual / Family)
$1,000 / $3,000
$5,000 / $9,000
Maximum Out-of-Pocket (Individual/Family)
$9,000 / $18,000
In-Network Only
$6,000 / $12,000
Unlimited
Lifetime Major Medical Maximum
Unlimited
50%
Coinsurance
50%
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