Medical

This chart gives an overview of the medical Copay plans administered by Cigna. As a member of a Copay plan, you can use the doctors and hospitals within the Open Access Plus In (OAPIN) network, but cannot go outside the network for care. There are no out-of-network benefits, except for emergency services. Refer to the medical benefits summary from Cigna for more details.

Medical	Copay Base
IN-NETWORK	OAPin
Primary Residence	Nationwide
Calendar Year Deductible	Embedded
Individual \| Family	$1250	$2500
Plan Coinsurance	70%
Out of Pocket Max (Coinsurance, Copays & Deductible Apply To Out of Pocket)	Embedded
Individual \| Family	$4500	$9000
Physician & Emergent Care
Preventive Care	No charge
PCP \| Specialist	CCN: $10 NCCN: $20	CCN: $35 NCCN: $50
PCP Required	No
Referral Required	No
Virtual Visits	$5
Convenience Care (i.e. CVS Minute Clinic)	$20
Urgent Care	$50
Emergency Room (In or out of network)	$500
Hospitalization & Outpatient Care
Inpatient	30% after deductible
Outpatient	30% after deductible
Physician Fees	30% after deductible
Independent Facility Care
Labs	No charge
X-rays	No charge
Complex Diagnostic Imaging	30% after deductible
Prescription Drugs	Mandatory Generic
Deductible	$0
Tier 1	$10
Tier 2	$35
Tier 3	$60
Specialty (GH, Self Injectable, etc)	$125
Mail Order - 90 day supply	2.5 x retail copay
OUT-OF-NETWORK
Deductible Individual \| Family	No benefits except emergency services
Plan Coinsurance	No benefits except emergency services
Out of Pocket Max	No benefits except emergency services
Office Charges	No benefits except emergency services
Facility Charges	No benefits except emergency services
Balance Billing	No benefits except emergency services

SBC OAPIN Base 2021 Holiday Inn Club Vacations, Inc

OAPIN Plans MA Rider

This chart gives an overview of the medical Copay plans administered by Cigna. As a member of a Copay plan, you can use the doctors and hospitals within the Open Access Plus In (OAPIN) network, but cannot go outside the network for care. There are no out-of-network benefits, except for emergency services. Refer to the medical benefits summary from Cigna for more details.

Medical	Copay High
IN-NETWORK	OAPin
Primary Residence	Nationwide
Calendar Year Deductible	Embedded
Individual \| Family	2020 (2021) $750 ($1000)	2020 (2021) $1500 ($2000)
Plan Coinsurance	80%
Out of Pocket Max (Coinsurance, Copays & Deductible Apply To Out of Pocket)	Embedded
Individual \| Family	2020 (2021) $3750 ($4000)	2020 (2021) $7500 ($8000)
Physician & Emergent Care
Preventive Care	No charge
PCP \| Specialist	CCN: $10 NCCN: $20	CCN: $35 NCCN: $50
PCP Required	No
Referral Required	No
Virtual Visits	$5
Convenience Care (i.e. CVS Minute Clinic)	$20
Urgent Care	$50
Emergency Room (In or out of network)	$500
Hospitalization & Outpatient Care
Inpatient	20% after deductible
Outpatient	20% after deductible
Physician Fees	20% after deductible
Independent Facility Care
Labs	No charge
X-rays	No charge
Complex Diagnostic Imaging	20% after deductible
Prescription Drugs	Mandatory Generic
Deductible	$0
Tier 1	$10
Tier 2	$35
Tier 3	$60
Specialty (GH, Self Injectable, etc)	$125
Mail Order - 90 day supply	2.5 x retail copay
OUT-OF-NETWORK
Deductible Individual \| Family	No benefits except emergency services
Plan Coinsurance	No benefits except emergency services
Out of Pocket Max	No benefits except emergency services
Office Charges	No benefits except emergency services
Facility Charges	No benefits except emergency services
Balance Billing	No benefits except emergency services

SBC OAPIN High 2021 Holiday Inn Club Vacations, Inc

OAPIN Plans MA Rider

This chart gives an overview of the medical Copay plans administered by Cigna. As a member of a Copay plan, you can use the doctors and hospitals within the Open Access Plus In (OAPIN) network, but cannot go outside the network for care. There are no out-of-network benefits, except for emergency services. Refer to the medical benefits summary from Cigna for more details.

Medical	CDHP Base
IN-NETWORK	OAP
Primary Residence	Nationwide
Calendar Year Deductible	Non-Embedded
Individual \| Family	$2000	$4000
Plan Coinsurance	80%
Out of Pocket Max (Coinsurance, Copays & Deductible Apply To Out of Pocket)	Embedded
Individual \| Family	$4000	$8000
Physician & Emergent Care
Preventive Care	No charge
PCP \| Specialist	20% after deductible
PCP Required	No
Referral Required	No
Virtual Visits	$5 Deductible waived
Convenience Care (i.e. CVS Minute Clinic)	20% after deductible
Urgent Care	20% after deductible
Emergency Room (In or out of network)	20% after deductible
Hospitalization & Outpatient Care
Inpatient	20% after deductible
Outpatient	20% after deductible
Physician Fees	20% after deductible
Independent Facility Care
Labs	20% after deductible
X-rays	20% after deductible
Complex Diagnostic Imaging	20% after deductible
Prescription Drugs	Mandatory Generic
Deductible	Medical deductible
Tier 1	$10 after deductible
Tier 2	$35 after deductible
Tier 3	$60 after deductible
Specialty (GH, Self Injectable, etc)	$125 after deductible
Mail Order - 90 day supply	2.5 x retail copay
OUT-OF-NETWORK
Deductible Individual \| Family	$4000	$8000
Plan Coinsurance	60%
Out of Pocket Max	$8000	$16000
Office Charges	40% after deductible
Facility Charges	40% after deductible
Balance Billing	Yes

SBC HDHPQ Base 2021 Holiday Inn Club Vacations, Inc

CDHP Plans MA Rider

This chart gives an overview of the medical Copay plans administered by Cigna. As a member of a Copay plan, you can use the doctors and hospitals within the Open Access Plus In (OAPIN) network, but cannot go outside the network for care. There are no out-of-network benefits, except for emergency services. Refer to the medical benefits summary from Cigna for more details.

Medical	CDHP High
IN-NETWORK	OAP
Primary Residence	Nationwide
Calendar Year Deductible	Non-Embedded
Individual \| Family	$2000	$4000
Plan Coinsurance	Your plan pays 100%	Your plan pays 80%
Out of Pocket Max (Coinsurance, Copays & Deductible Apply To Out of Pocket)	Embedded
Individual \| Family	$4000	$8000
Physician & Emergent Care
Preventive Care	No charge
PCP \| Specialist	Deductible
PCP Required	No
Referral Required	No
Virtual Visits	$5 Deductible waived
Convenience Care (i.e. CVS Minute Clinic)	Deductible
Urgent Care	Deductible
Emergency Room (In or out of network)	Deductible
Hospitalization & Outpatient Care
Inpatient	Deductible
Outpatient	Deductible
Physician Fees	Deductible
Independent Facility Care
Labs	Deductible
X-rays	Deductible
Complex Diagnostic Imaging	Deductible
Prescription Drugs	Mandatory Generic
Deductible	Medical deductible
Tier 1	$10 after deductible
Tier 2	$35 after deductible
Tier 3	$60 after deductible
Specialty (GH, Self Injectable, etc)	$125 after deductible
Mail Order - 90 day supply	2.5 x retail copay
OUT-OF-NETWORK
Deductible Individual \| Family	$4000	$8000
Plan Coinsurance	80%
Out of Pocket Max	$8000	$16000
Office Charges	20% after deductible
Facility Charges	20% after deductible
Balance Billing	Yes

SBC HDHPQ High 2021 Holiday Inn Club Vacations, Inc

CDHP Plans MA Rider

This chart provides an overview of the medical CDHP plans administered by Cigna. As a member of a CDHP SureFit plan, you can use the doctors and hospitals within the SureFit network. You have access to doctors and hospitals within the SureFit network but cannot go outside the network for care. There are no out-of-network benefits, except for emergency services. Refer to the medical benefits summary from Cigna for more details.

Medical	CDHP Surefit Non-Embedded
IN-NETWORK	SureFit
Primary Residence	Lake, Orange, Osceola and Seminole County Florida
Calendar Year Deductible	Non-Embedded
Individual \| Family	$2250	$4500
Plan Coinsurance	70%
Out of Pocket Max (Coinsurance, Copays & Deductible Apply To Out of Pocket)	Embedded
Individual \| Family	$4500	$9000
Physician & Emergent Care
Preventive Care	No charge
PCP \| Specialist	30% after deductible
PCP Required	Yes
Referral Required	Yes
Virtual Visits	$5 Deductible waived
Convenience Care (i.e. CVS Minute Clinic)	30% after deductible
Urgent Care	30% after deductible
Emergency Room (In or out of network)	30% after deductible
Hospitalization & Outpatient Care
Inpatient	30% after deductible
Outpatient	30% after deductible
Physician Fees	30% after deductible
Independent Facility Care
Labs	30% after deductible
X-rays	30% after deductible
Complex Diagnostic Imaging	30% after deductible
Prescription Drugs	Mandatory Generic
Deductible	Medical deductible
Tier 1	$10 after deductible
Tier 2	$35 after deductible
Tier 3	$60 after deductible
Specialty (GH, Self Injectable, etc)	$125 after deductible
Mail Order - 90 day supply	2.5 x retail copay
OUT-OF-NETWORK
Deductible Individual \| Family	No benefits except emergency services
Plan Coinsurance	No benefits except emergency services
Out of Pocket Max	No benefits except emergency services
Office Charges	No benefits except emergency services
Facility Charges	No benefits except emergency services
Balance Billing	No benefits except emergency services

SBC Surefit Qualified 2021 Holiday Inn Club Vacations Inc

Central Florida SureFit Directory

Copay Base Plan

Copay High Plan

CDHP Base Plan

CDHP High Plan

CDHP SureFit Plan