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Employee Pays
Services Outside of
the United States
Services Received in the United States
In-Network
Out-of-Network
Deductible
Individual
Family
$0
$0
$1,500
$3,000
$3,000
$6,000
Maximum Out of Pocket
Individual
Family
$0
$0
$4,000
$8,000
$ 8,000
$16,000
Lifetime Maximum
Unlimited
Unlimited
Physician Service
100% Covered
$50 Copay
40% After Deductible
Inpatient Services
100% Covered
20% After Deductible
40% After Deductible
Outpatient Services
100% Covered
20% After Deductible
40% After Deductible
Precertification Penalty
N/A outside U.S.
$300 Penalty for failure to Precertify
And benefits reduced by 50%
Urgent Care
100% Covered
$50 Copay
$50 Copay
Hospital Emergency Room
100% Covered
20% After Ded.
+ $250 Copay
20% After Ded.
+ $250 Copay
Preventive Care
Wellness Care
Routine Physical Exams
Gynecological Exams
PSA & DRE
Mammograms
100% Covered
100% Covered
40% Deductible Waived
Home Health Care
(120 days per calendar year)
100% Covered
20% After Deductible
40% After Deductible
Chiropractic Treatment
100% Covered
20%
40% After Deductible
Alcoholism, Drug Abuse and
Mental Disorder
Inpatient
Outpatient
100% Covered
100% Covered
20% After Deductible
$40 Copay
40% After Deductible
40% After Deductible
Emergency Medical Evacuation
100% Covered
100% Covered – Not subject to deductible
Prescription Drugs
Tier 1 (Generic)
Tier 2 (Preferred)
Tier 3 (Non-Preferred Brand)
100% Covered
100% Covered
100% Covered
$15 per RX
$50 per RX
$90 per RX
40% Deductible Waived
40% Deductible Waived
40% Deductible Waived
Vision
100% Covered
Once every 24 months.
100% Covered
Once every 24 months.
40% (Not subject to deductible)
Once every 24 months
CIGNA GLOBAL OPEN ACCESS PLUS (OAP)
GLOBAL PLAN