|
|
OAPIN
|
|
Open Access+Network
|
Out-of-Network
|
|
Office Visit
|
|
|
|
Primary Care Physician
|
$40
|
No Coverage
|
|
Specialist
|
$80
|
No Coverage
|
|
Consigilio Wellness Center
|
$0
|
|
|
Deductible
|
|
|
|
Individual
|
$500
|
N/A
|
|
Individual + More
|
$1,000
|
N/A
|
|
Coinsurance
|
20%
|
No Coverage
|
|
Out-of-Pocket Maximum
|
|
|
|
Individual
(includes deductible)
|
$3,000
|
N/A
|
|
Individual + More
(includes deductible)
|
$6,000
|
N/A
|
|
|
|
|
|
|
OAPIN
|
|
Prescription Drug
|
Preventive
|
Non-Preventive
|
|
Retail In-Network
(34 day supply)
|
|
|
|
Generic
|
$0
|
$15
|
|
Preferred Brand
|
$25
|
$25
|
|
Non-Preferred Brand
|
$40
|
$40
|
|
Mail Order In-Network
(90 day supply)
|
|
|
|
Generic
|
$0
|
$30
|
|
Preferred Brand
|
$50
|
$50
|
|
Non-Preferred Brand
|
$80
|
$80
|