Help choosing between Horizon EPO Design 2 Medical Plan and Cigna OAPIN Medical Plan

State:Texas

Horizon $78 Biweekly

What is the overall deductible?

$2,500.00 Individual/$5,000.00 Family for in-network.

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

Are there services covered before you meet your deductible?

Yes. Preventive care is covered before you meet your deductible.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.

Arethereotherdeductibles No. Youdon’thavetomeetdeductiblesforspecificservices. for specific services?

Whatisnotincludedinthe Premiums,balance-billingchargesandEventhoughyoupaytheseexpenses,theydon’tcounttowardtheout-of-pocket

What is the out-of-pocket limit for this plan?

For in-network Health/Pharmacy providers $5,000.00Individual/$10,000.00 Family. Aggregate family.

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of- pocket limits until the overall family out-of-pocket limit has been met.

out-of-pocket limit?

Do you need a referral to see a specialist?

health care this plan doesn’t cover.

No.

limit.

You can see the specialist you choose without a referral.

(Prescription/Advantage EPO)/BlueCard

Will you pay less if you use a network provider?

Yes. For a list of network providers, see www.HorizonBlue.com or call 1- 800-355-BLUE(2583).

This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider , and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

Open Access Plus IN PlanOAPIN–$70 Bi-weekly

Effective – 01/01/2023

Selection of a Primary Care Provider – your plan may require or allow the designation of a primary care provider. You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members. If your plan requires designation of a primary care provider, Cigna may designate one for you until you make this designation. For information on how to select a primary care provider, and for a list of the participating primary care providers, visit www.mycigna.com or contact customer service at the phone number listed on the back of your ID card. For children, you may designate a pediatrician as the primary care provider.

Direct Access to Obstetricians and Gynecologists – You do not need prior authorization from the plan or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, visit www.mycigna.com or contact customer service at the phone number listed on the back of your ID card.

A notice for Texas residents per Tex. Ins. Code §1218.001 et.al.: This plan has purchased an optional rider to cover elective abortions. The enrollee has the right to exclude from their plan, and not pay for, coverage for elective abortions.

Plan Highlights

In-Network

Lifetime Maximum Unlimited

Plan Year Accumulation

Plan Coinsurance Plan pays 70%

Your Plan’s Deductibles, Out-of-Pockets and benefit level limits accumulate on a calendar year basis unless otherwise stated.

Maximum Reimbursable Charge Not Applicable

Individual: $2,500 Family: $5,000

Plan Deductible

  Benefit copays/deductibles always apply before plan deductible and coinsurance.

  Family members meet only their individual deductible and then their claims will be covered under the plan coinsurance; if the family deductible has been met
prior to their individual deductible being met, their claims will be paid at the plan coinsurance. Note: Services where plan deductible applies are noted with a caret (^).

Individual: $5,000 Family: $10,000

Plan Out-of-Pocket Maximum

  Plan deductible contributes towards your out-of-pocket maximum.

  All benefit copays/deductibles contribute towards your out-of-pocket maximum.

  Covered expenses that count towards your out-of-pocket maximum include customer paid coinsurance and charges for Mental Health and Substance Use
Disorder.

  After each eligible family member meets his or her individual out-of-pocket maximum, the plan will pay 100% of their covered expenses. Or, after the family
out-of-pocket maximum has been met, the plan will pay 100% of each eligible family member’s covered expenses.

  This plan includes a combined Medical/Pharmacy out-of-pocket maximum.

Benefit

In-Network

Note: Services where plan deductible applies are noted with a caret (^). Benefit copays/deductibles always apply before plan deductible.

Physician Services – Office Visits

Primary Care Physician (PCP) Services/Office Visit $25 copay, and plan pays 100%

Specialty Care Physician Services/Office Visit $50 copay, and plan pays 100%

NOTE: Obstetrician and Gynecologist (OB/GYN) visits are subject to either the PCP or Specialist cost share depending on how the provider contracts with Cigna (i.e. as PCP or as Specialist).

Surgery Performed in Physician’s Office Covered same as Physician Services – Office Visit

Allergy Treatment/Injections and Allergy Serum

Allergy serum dispensed by the physician in the office
Note: Office copay does not apply if only the allergy serum is provided.

Covered same as Physician Services – Office Visit

Virtual Care

Dedicated Virtual Providers – MDLIVE

MDLIVE Urgent Virtual Care Services $25 copay, and plan pays 100%

  Dedicated Virtual Providers may deliver services that are payable under other benefits (e.g., Preventive Care, Primary Care Physician, Behavioral;
Dermatology/Specialty Care Physician).

  Lab services supporting a virtual visit must be obtained through dedicated labs.

  Includes charges for the delivery of medical and health-related services and consultations by dedicated virtual providers as medically appropriate through
audio, video, and secure internet-based technologies.

Preventive Care

Preventive Care Plan pays 100%

  Includes coverage of additional services, such as urinalysis, EKG, and other laboratory tests, supplementing the standard Preventive Care benefit when
billed as part of office visit.

  Annual Limit: Unlimited

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Immunizations Plan pays 100%

Mammogram, PAP, and PSA Tests Plan pays 100%

  Coverage includes the associated Preventive Outpatient Professional Services.

  Diagnostic-related services are covered at the same level of benefits as other x-ray and lab services, based on Place of Service.📷

Inpatient

Inpatient Hospital Facility Services Plan pays 70% ^
Note: Includes all Lab and Radiology services, including Advanced Radiological Imaging as well as Medical Specialty Drugs

Inpatient Hospital Physician’s Visit/Consultation Plan pays 70% ^

Inpatient Professional Services Plan pays 70% ^  For services performed by Surgeons, Radiologists, Pathologists and Anesthesiologists

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Benefit

In-Network

Note: Services where plan deductible applies are noted with a caret (^). Benefit copays/deductibles always apply before plan deductible.

Outpatient

Outpatient Facility Services Plan pays 70% ^

Outpatient Professional Services Plan pays 70% ^  For services performed by Surgeons, Radiologists, Pathologists and Anesthesiologists

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Emergency Services

Emergency Room

  Includes Professional, X-ray and/or Lab services performed at the Emergency Room and billed by the facility as part of the ER visit.

  Per visit copay is waived if admitted.

$100 copay, and plan pays 100%

Urgent Care Facility

 Includes Professional, X-ray and/or Lab services performed at the Urgent Care Facility and billed by the facility as part of the urgent care visit.

$50 copay, and plan pays 100%

Ambulance Plan pays 70% ^
Ambulance services used as non-emergency transportation (e.g., transportation from hospital back home) generally are not covered.

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Inpatient Services at Other Health Care Facilities

Skilled Nursing Facility, Rehabilitation Hospital, Sub-Acute Facilities

 Annual Limit: 100 days

Plan pays 70% ^

Laboratory Services

Physician’s Services/Office Visit Plan pays 100%

Independent Lab Plan pays 70%

Outpatient Facility Plan pays 70% ^

Radiology Services

Physician’s Services/Office Visit Plan pays 100%

Outpatient Facility Plan pays 70% ^

Advanced Radiological Imaging (ARI)

Includes MRI, MRA, CAT Scan, PET Scan, etc.

Outpatient Facility Plan pays 70% ^

Physician’s Services/Office Visit Covered same as Physician Services – Office Visit

Outpatient Therapy Services

Outpatient Therapy Services Covered same as Physician Services – Office Visit Annual Limits:

  All Therapies Combined – Includes Cognitive Therapy, Occupational Therapy, Physical Therapy, Pulmonary Rehabilitation, and Speech Therapy – 60 days

  Limits are not applicable to mental health conditions for Physical, Speech and Occupational Therapies.
Note: Therapy days, provided as part of an approved Home Health Care plan, accumulate to the applicable outpatient therapy services maximum.

Benefit

Note: Services where plan deductible applies are noted with a caret (^). Benefit copays/deductibles always apply before plan deductible.

In-Network

📷📷

Chiropractic Services Covered same as Physician Services – Office Visit Annual Limit:

 Chiropractic Care – 60 days

📷📷

Cardiac Rehabilitation Services Covered same as Physician Services – Office Visit Annual Limit:

 Cardiac Rehabilitation – 36 days

and more