BENEFIT HIGHLIGHTS
IN-NETWORK
OUT-OF-NETWORK
Virtual Care Dedicated Virtual Providers Dedicated virtual care services may be provided by MDLIVE, a Cigna affiliate. Services available through contracted virtual providers as medically appropriate. Notes: • Primary Care cost share applies to routine care. Virtual wellness screenings are payable under preventive care. • MDLIVE Behavioral Services, please refer to the Mental Health and Substance Use Disorder section (below). • Lab services supporting a virtual visit must be obtained through dedicated labs. MDLIVE Urgent Care Services MDLIVE Primary Care Services MDLIVE Specialty Care Services Virtual Physician Services Services available through Physicians as medically appropriate. Note: Physicians may deliver services virtually that are payable under other benefits (e.g., Preventive Care, Outpatient Therapy Services). Physician Virtual Office Visit
80% after plan deductible 80% after plan deductible 80% after plan deductible
In-Network coverage only In-Network coverage only In-Network coverage only
80% after plan deductible
50% of the Maximum Reimbursable Charge after plan deductible
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