Medical
JL Marine Systems offers two medical plans through Cigna. The below chart provides an overview and comparison of these plans. To find a participating provider, visit www.mycigna.com.
OAP HSA Sportsman
OAPIN 2000 Blade
IN-NETWORK: Plan Year or Calendar Year Basis
Calendar Year
Calendar Year
Deductible (Individual / Family) Coinsurance (Cigna / Member)
$3,000 / $6,000
$2,000/ $4,000
60% / 40%
80% / 20%
Maximum Out-of-Pocket (Individual/Family)
$6,000 / $12,000
$4,000 / $8,000
Maximum Out-of-Pocket Includes
Deductible, Coinsurance & Copayments Eligible – Health Savings Account page
Deductible, Coinsurance & Copayments
Health Savings Account
Not Eligible
PREVENTIVE CARE:
Wellness Immunizations Mammography/Colonoscopy COPAYMENTS: Virtual Visits (Telemedicine)
Covered 100%
Covered 100%
No Referral Required
No Referral Required
40% Coinsurance, after Deductible
$25 Copay
Office Visits Consultations for Illness/Injury
40% Coinsurance, after Deductible
$25 Copay
Specialist Visits Inpatient Hospital Outpatient Surgery Emergency Room
40% Coinsurance, after Deductible 40% Coinsurance, after Deductible 40% Coinsurance, after Deductible 40% Coinsurance, after Deductible 40% Coinsurance, after Deductible 40% Coinsurance, after Deductible
$45 Copay
20% after deductible 20% after deductible
$500 Copay $50 Copay
Urgent Care
OUTPATIENT DIAGNOSTIC SERVICES:
Independent/Freestanding Lab X-Rays
40% Coinsurance, after Deductible
Covered 100%
Complex Diagnostic (MRI, CT, PET, Etc.) – Freestanding Facility
40% Coinsurance, after Deductible
$500 Copay
PRESCRIPTIONS:
After Deductible
Tier 1: $10 Copay Tier 2: $50 Copay Tier 3: $80 Copay Tier 4: $150 Copay
Tier 1: $10 Copay Tier 2: $50 Copay Tier 3: $80 Copay
Retail (30 day supply)
3 x Copay
Mail Order (90 day supply)
3 x Copay
OUT-OF-NETWORK: Deductible (Individual / Family)
$6,000/$12,000
$4,000 / $8,000
Coinsurance
60% / 40%
50% / 50%
Maximum Out-of-Pocket (Individual/Family)
$12,000 / $24,000
$8,000 / $16,000
The chart below provides a brief overview of the medical plans. This chart is intended only to highlight the benefits 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.
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