Medical Benefits Plan Comparison
Cigna OAP High Plan
Cigna OAP Low Plan
In-Network
Out-of-Network
In-Network Only
Deductible and Coinsurance
Primary Care Visit
$20 Copay
$25 Copay
Deductible and Coinsurance
Specialist Office Visit
$50 Copay
$50 Copay
Deductible and Coinsurance
Urgent Care Visit
$25 Copay
$25 Copay
Prescription Drug Retail
$15/$30/$60
N/A
$20/$30/$60
Prescription Drug Mail Order
$30/$60/$120
N/A
$40/$60/$120
Emergency Room
$100 Copay
$100 Copay
Plan pays 100% after Deductible
Deductible and Coinsurance
Plan pays 100% after Deductible
Inpatient Services
Plan pays 100% after Deductible
Deductible and Coinsurance
Plan pays 100% after Deductible
Outpatient Services
Outpatient Lab and X-ray
Deductible and Coinsurance
Plan pays 100%
Plan pays 100%
Plan pays 100% after Deductible
Deductible and Coinsurance
Plan pays 100% after Deductible
Radiology
Coinsurance
Plan pays 100%
Plan pays 80%
Plan pays 100%
Lifetime Maximum
Unlimited
Annual Out-of-Pocket Maximum
$5,350/$10,700
$2,000/$4,000
$6,350/$12,700
Annual Deductible
$1,000/$3,000
$1,000/$3,000
$1,000/$3,000
2024-2025 Benefit Summary
8
Made with FlippingBook - PDF hosting