2026 Benefits
Base Copay Medical Plan
Balanced PPO with predictable copays for everyday care.
Plan Details
Base Copay (PPO with Copays) is offered through Cigna on the Cigna OAP network. Review the details below to understand your coverage, costs, and pharmacy benefits.
FSA Eligible
Yes
HRA Included
No
Eligible States
All states
Semimonthly Payroll Contribution
| Coverage Tier | Employee Cost |
|---|---|
| Employee Only | $81.53 |
| Employee + Spouse | $294.28 |
| Employee + Children | $259.88 |
| Family | $386.00 |
Employee Only
Employee Cost$81.53
Employee + Spouse
Employee Cost$294.28
Employee + Children
Employee Cost$259.88
Family
Employee Cost$386.00
Calendar Year Deductible
| Tier | In-Network | Out-of-Network |
|---|---|---|
| Individual | $3,500 | $7,000 |
| Family | $7,000 | $14,000 |
Individual
In-Network$3,500
Out-of-Network$7,000
Family
In-Network$7,000
Out-of-Network$14,000
Out-of-Pocket Maximum
| Tier | In-Network | Out-of-Network |
|---|---|---|
| Individual | $7,000 | $15,000 |
| Family | $14,000 | $30,000 |
Individual
In-Network$7,000
Out-of-Network$15,000
Family
In-Network$14,000
Out-of-Network$30,000
Coinsurance (Plan Pays)
| In-Network | Out-of-Network | |
|---|---|---|
| After Deductible | 80% | 50% |
After Deductible
In-Network80%
Out-of-Network50%
Covered Services
| Service | In-Network | Out-of-Network |
|---|---|---|
| Preventive Care | Covered 100% | Not covered |
| Primary Care | $30 copay | 50% after deductible |
| Specialist Services | $50 copay | 50% after deductible |
| Diagnostic Care | 20% after deductible | 50% after deductible |
| Urgent Care | $75 copay | 50% after deductible |
| Emergency Room | $300 copay + 20% | $300 copay + 20% |
Preventive Care
In-NetworkCovered 100%
Out-of-NetworkNot covered
Primary Care
In-Network$30 copay
Out-of-Network50% after deductible
Specialist Services
In-Network$50 copay
Out-of-Network50% after deductible
Diagnostic Care
In-Network20% after deductible
Out-of-Network50% after deductible
Urgent Care
In-Network$75 copay
Out-of-Network50% after deductible
Emergency Room
In-Network$300 copay + 20%
Out-of-Network$300 copay + 20%
Pharmacy Benefits — Retail (30-Day Supply)
| Tier | Cost |
|---|---|
| Preferred Generic | $10 |
| Preferred Brand | $35 |
| Non-Preferred | $60 |
| Specialty | $250 |
Preferred Generic
Cost$10
Preferred Brand
Cost$35
Non-Preferred
Cost$60
Specialty
Cost$250
Pharmacy Benefits — Mail Order (90-Day Supply)
| Tier | Cost |
|---|---|
| Preferred Generic | $25 |
| Preferred Brand | $88 |
| Non-Preferred | $150 |
Preferred Generic
Cost$25
Preferred Brand
Cost$88
Non-Preferred
Cost$150