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CIGNA OAP 500
CIGNA OAP 500
Employee Pays
In-Network
Out-of-Network
Deductible*
Individual
Family
$500
$1,500
$1,000***
$3,000 ***
Maximum Out of Pocket (OOP)**
Individual
Family
$3,000
$6,000
$6,000***
$12,000***
Lifetime Maximum
Unlimited
Office Visits
Primary Care Provider
$40 Co-pay
30% After Deductible
Preventive Care
Child Services (up to age 13)
Adults’ Services
0% (Not subject to Deductible)
0% (Not subject to Deductible)
30% After Deductible
Inpatient Services****
10% After Deductible
30% After Deductible
Outpatient Services****
Surgery / Therapeutic
Lab / X-rays
10% After Deductible
10% After Deductible
30% After Deductible
30% After Deductible
Emergency Care
10% After Deductible
10% After Deductible
Urgent Care
$40 Co-pay per visit
$40 Copay per visit
Ambulance
10% After In Network Deductible
10% After In Network Deductible
Skilled Nursing Facility
(100 Days per calendar year in- and out-
of-network combined)
10% After Deductible
30% After Deductible
Home Health Care
(100 Days per calendar year)
10% After Deductible
30% After Deductible
Durable Medical Equipment
10% After Deductible
30% After Deductible
Vision
Not Covered
Not Covered
Substance Abuse Service
Inpatient
Outpatient Office/Facility
10% After Deductible
$40 Co-pay/10% After Deductible
30% After Deductible
30% After Deductible
Mental Health
Inpatient
Outpatient Office/Facility
10% After Deductible
$40 Copay/10% After Deductible
30% After Deductible
30% After Deductible
Prescription Drugs***
Tier 1 (Generic)
Tier 2 (Preferred Brand)
Tier 3 (Non-Preferred Brand)
Mail Order – Tier 1 - 3
$15
You pay 30%, max of $50
You pay 55%, max of $50
T1 $38 / T2 30% / T3 55% - Max of $125
Not Covered
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