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
No charge after the $20 per visit copay No charge after the $20 per visit copay No charge after the $20 per visit copay
In-Network coverage only
MDLIVE Primary Care Services
In-Network coverage only
MDLIVE Specialty Care Services
In-Network coverage only
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
No charge after the $30 PCP or $40 Specialist per office visit copay
50% of the Maximum Reimbursable Charge after plan deductible
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