Cigna OAPIN

Copay-based in-network plan.

Cigna OAPIN

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Plan Details

Carrier

Cigna

Network Name

Cigna

Plan Type

OAPIN

HSA Eligible

FSA Eligible

Yes

HRA Included

Premiums

Frequency: Biweekly

Coverage Tier	With LiveWell Credit	Without LiveWell Credit
EE Only	$95.00	$129.62
EE + Children	$194.00	$228.62
EE + Spouse	$235.00	$269.62
EE + Family	$338.00	$372.62

EE Only

With LiveWell Credit: $95.00
Without LiveWell Credit: $129.62

EE + Children

With LiveWell Credit: $194.00
Without LiveWell Credit: $228.62

EE + Spouse

With LiveWell Credit: $235.00
Without LiveWell Credit: $269.62

EE + Family

With LiveWell Credit: $338.00
Without LiveWell Credit: $372.62

Deductible, Out-of-Pocket & Coinsurance

Feature	Network
Out-of-Pocket Max (Individual)	$2,500
Out-of-Pocket Max (Family)	$5,000
Employer Contribution - Per Individual	N/A
Employer Contribution - Per Family	N/A

Out-of-Pocket Max (Individual)

Network: $2,500

Out-of-Pocket Max (Family)

Network: $5,000

Employer Contribution - Per Individual

Network: N/A

Employer Contribution - Per Family

Network: N/A

Covered Services

Service	Network
Preventive Care	100% covered
LW Clinic Visit	100% covered
Office Visits	$30 copayment
Specialist Office Visits	$60 copayment
Outpatient Surgery	Office visit copayment if performed in physician’s office; $200 copayment if performed in hospital or outpatient facility, then covered 100%
Hospitalization and Inpatient Surgery	$500 copayment per admission, then covered 100%
Mental Health	Inpatient: $500 copayment per admission, then covered 100% Outpatient: $30 copayment per visit
Virtual visits	$0 copayment
Urgent Care Facility	$75 copayment
Emergency Room	$150 copayment; waived if admitted to a hospital or outpatient facility
Ambulance	$150 copayment

Preventive Care

Network: 100% covered

LW Clinic Visit

Network: 100% covered

Office Visits

Network: $30 copayment

Specialist Office Visits

Network: $60 copayment

Outpatient Surgery

Network: Office visit copayment if performed in physician’s office; $200 copayment if performed in hospital or outpatient facility, then covered 100%

Hospitalization and Inpatient Surgery

Network: $500 copayment per admission, then covered 100%

Mental Health

Network: Inpatient: $500 copayment per admission, then covered 100% Outpatient: $30 copayment per visit

Virtual visits

Network: $0 copayment

Urgent Care Facility

Network: $75 copayment

Emergency Room

Network: $150 copayment; waived if admitted to a hospital or outpatient facility

Ambulance

Network: $150 copayment

* After deductible

Pharmacy Benefits

Tier	Channel	Cost
Tier 1 Generic Drugs	Retail Rx (up to 30-day supply)	$5 copayment
Tier 2 Brand-name drugs (on the Preferred Drug List)	Retail Rx (up to 30-day supply)	$30 copayment
Tier 3 Brand-name drugs (not on the Preferred Drug List)	Retail Rx (up to 30-day supply)	$60 copayment
Tier 4 Specialty retail drugs (injection, infused or oral)	Retail Rx (up to 30-day supply)	$100 copayment (30-day supply)
Tier 1 Generic Drugs	Mail Order Rx (31 to 90-day supply)	$10 copayment
Tier 2 Brand-name drugs (on the Preferred Drug List)	Mail Order Rx (31 to 90-day supply)	$60 copayment
Tier 3 Brand-name drugs (not on the Preferred Drug List)	Mail Order Rx (31 to 90-day supply)	$120 copayment
Tier 4 Specialty mail order drugs (injection, infused or oral)	Mail Order Rx (31 to 90-day supply)	$100 copayment (30-day supply)

Tier 1 Generic Drugs

Channel: Retail Rx (up to 30-day supply)
Cost: $5 copayment

Tier 2 Brand-name drugs (on the Preferred Drug List)

Channel: Retail Rx (up to 30-day supply)
Cost: $30 copayment

Tier 3 Brand-name drugs (not on the Preferred Drug List)

Channel: Retail Rx (up to 30-day supply)
Cost: $60 copayment

Tier 4 Specialty retail drugs (injection, infused or oral)

Channel: Retail Rx (up to 30-day supply)
Cost: $100 copayment (30-day supply)

Tier 1 Generic Drugs

Channel: Mail Order Rx (31 to 90-day supply)
Cost: $10 copayment

Tier 2 Brand-name drugs (on the Preferred Drug List)

Channel: Mail Order Rx (31 to 90-day supply)
Cost: $60 copayment

Tier 3 Brand-name drugs (not on the Preferred Drug List)

Channel: Mail Order Rx (31 to 90-day supply)
Cost: $120 copayment

Tier 4 Specialty mail order drugs (injection, infused or oral)

Channel: Mail Order Rx (31 to 90-day supply)
Cost: $100 copayment (30-day supply)

Plan Notes

Pharmacy benefits are administered through Cigna and Express Scripts.
Preventive drug costs may be $0 cost to you.
Home delivery through Express Scripts Pharmacy — enroll at mycigna.com or myCigna app or call 800-835-3784.
Preventive Medication Program: Medications covered for chronic health conditions at a $0 copayment. Call 800-244-6224.
Prior Authorization Program: Requires prior authorization for certain medications.
Step Therapy Program: Requires you to try a proven, cost-effective medication before a more costly treatment.