Medical
Medical coverage protects you and your family. You will have less out-of-pocket costs if you go to an in-network provider versus an out-of-network provider. Out-of-network providers may charge more if their fees exceed standard limits.
You may be responsible for the difference between what the plan will pay and what the provider or facility charges.
Preventive care, like exams and flu shots, is covered at 100% when you use an in-network provider. The main difference between plans is how much you pay each period and when you need care.
Each plan has different:
- Annual deductible amounts – the amount you pay each year for eligible in-network and out-of-network charges before the plan begins to pay.
- Out-of-pocket maximums – the most you will pay each year for eligible network services and/or prescriptions. After you reach your out-of-pocket maximum, the plan picks up the full cost of covered medical care for the remainder of the year.
- Copays – A copay is a fixed amount you pay for a health care service. Copays do not count toward your deductible but do count toward your annual out-of-pocket maximum.
- Coinsurance – Once you’ve met your deductible, you and the plan share the cost of care, which is called coinsurance. For example, you pay 20% for services and the plan will pay 80% of the cost until you have reached your out-of-pocket maximum.
CIGNA OAPIN High – Option 1
Plan Information
Plan Name: CIGNA OAPIN High – Option 1
Policy Number: 00631187
Effective Date: 01/01/2025
Provider Network: Cigna
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$600/$1,200
Out-of-Pocket Max (Individual/Family)
$6,000/$12,000
Preventive Care
$0
Primary Care Visit
$50 copay
Specialist Visit
$50 copay
Urgent Care
$50 copay
Emergency Room
$500 copay, waived if admitted
Retail Rx (Up to 30-Day Supply)
Generic
$15 copay
Preferred Brand
$35 copay
Non-Preferred Brand
$75 copay
Specialty
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Generic
$45 copay
Preferred Brand
$105 copay
Non-Preferred Brand
$225 copay
Specialty
Not covered
Plan Documents & Costs
Contact Information
CIGNA OAPIN Low – Option 2
Plan Information
Plan Name: CIGNA OAPIN Low – Option 2
Policy Number: 00631187
Effective Date: 01/01/2025
Provider Network: Cigna
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$3,000/$6,000
Out-of-Pocket Max (Individual/Family)
$7,000/$14,000
Preventive Care
$0
Primary Care Visit
$30 copay
Specialist Visit
$50 copay
Urgent Care
$50 copay
Emergency Room
$500 copay, waived if admitted
Retail Rx (Up to 30-Day Supply)
Generic
$20 copay
Preferred Brand
$50 copay
Non-Preferred Brand
$80 copay
Specialty
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Generic
$60 copay
Preferred Brand
$150 copay
Non-Preferred Brand
$240 copay
Specialty
Not covered
Plan Documents & Costs
Contact Information
CIGNA OAP High – Option 3
Plan Information
Plan Name: CIGNA OAP High – Option 3
Policy Number: 00631187
Effective Date: 01/01/2025
Provider Network: Cigna
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$750/$1,500
Out-of-Pocket Max (Individual/Family)
$3,000/$6,000
Preventive Care
$0
Primary Care Visit
$25 copay
Specialist Visit
$40 copay
Urgent Care
$40 copay
Emergency Room
$300 copay, waived if admitted
Retail Rx (Up to 30-Day Supply)
Generic
$15 copay
Preferred Brand
$30 copay
Non-Preferred Brand
$60 copay
Specialty
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Generic
$45 copay
Preferred Brand
$90 copay
Non-Preferred Brand
$180 copay
Specialty
Not covered
Out-of-Network
Deductible (Individual/Family)
$2,000/$4,000
Out-of-Pocket Max (Individual/Family)
$5,000/$10,000
Preventive Care
30%
Primary Care Visit
30% after deductible
Specialist Visit
30% after deductible
Urgent Care
30% after deductible
Emergency Room
$300 copay waived if admitted
Retail Rx (Up to 30-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Plan Documents & Costs
Contact Information
CIGNA OAP HSA – Option 4
Plan Information
Plan Name: CIGNA OAP HSA – Option 4
Policy Number: 00631187
Effective Date: 01/01/2025
Provider Network: Cigna
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$3,000/$6,000
Out-of-Pocket Max (Individual/Family)
$6,000/$12,000
Preventive Care
$0
Primary Care Visit
10% after deductible
Specialist Visit
10% after deductible
Urgent Care
10% after deductible
Emergency Room
10% after deductible
Retail Rx (Up to 30-Day Supply)
Generic
$15 copay
Preferred Brand
$35 copay
Non-Preferred Brand
$75 copay
Specialty
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Generic
$45 copay
Preferred Brand
$105 copay
Non-Preferred Brand
$225 copay
Specialty
Not covered
Out-of-Network
Deductible (Individual/Family)
$4,000/$8,000
Out-of-Pocket Max (Individual/Family)
$10,500/$21,000
Preventive Care
30%
Primary Care Visit
30% after deductible
Specialist Visit
30% after deductible
Urgent Care
30% after deductible
Emergency Room
10% after deductible
Retail Rx (Up to 30-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered