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CIGNA GLOBAL OPEN ACCESS PLUS (OAP)
CATASTROPHIC PLAN
78
Employee Pays
Services Received
Outside of the United
States
Services Received in the United States
In-Network
Out-of-Network
Deductible
Individual
$10,000 per calendar
year
$10,000 per calendar year
$15,000 per calendar
year
Maximum Out of
Individual
Family – No
Coverage
$2,000
None
$2,000
None
$2,000
None
Lifetime Maximum
Unlimited
Unlimited
Physician Service
30% After Deductible
$30 Copay
50% After Deductible
Inpatient Services
30% After Deductible
30% After Deductible
50% After Deductible
Outpatient Services
30% After Deductible
30% After Deductible
50% After Deductible
Precertification Penalty
N/A outside U.S.
$300 Penalty for failure to Precertify
And benefits reduced by 50%
Preventive Care
Wellness Care
Routine Physical
Exams
Gynecological Exams
PSA & DRE
Mammograms
100% Covered
100% Covered
50% Not subject to
plan deductible
Home Health Care
(120 visits per
calendar year)
30% After Deductible
30% After Deductible
50% After Deductible
Chiropractic Treatment
30% After Deductible
25%
50% After Deductible
Alcoholism, Drug Abuse
and Mental Disorder
Inpatient
Outpatient
30% After Deductible
30% After Deductible
30% After Deductible
$30 Copay
50% After Deductible
50% After Deductible
Emergency Medical
Evacuation
100% Covered – Not
subject to deductible
100% Covered – Not subject to deductible
Prescription Drugs
Tier 1 (Generic)
Tier 2 (Brand)
30% Deductible Waived
30% Deductible Waived
30% Deductible Waived
30% Deductible Waived
50% Deductible
Waived
50% Deductible
Waived