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Please note, the following chart presents only the highlights of your medical plan. More detailed information can be found in the Summary Plan Description.

Key Features

In-Network

Out-of-Network

$2,000Just You

No Coverage Just You

Deductible per Calendar Year

$4,000You + Family

No Coverage You + Family

$4,000Just You

Just You

No Coverage

Out-of-Pocket Maximum per Calendar Year

$8,000You + Family

You + Family

No Coverage

Coinsurance

80%

No Coverage

Physician Services

Annual Preventive Care Visit

100%, deductible waived

No Coverage

Physician Office Visit

80%

No Coverage

Specialist Office Visit

80%

No Coverage

Physical & Occupational Therapy - maximum visits per year: 60 Speech Therapy - maximum visits per year: 60 Chiropractic Therapy - maximum visits per year: 60

80%

No Coverage

80%

No Coverage

80%

No Coverage

X-Rays / Lab Diagnostics

80%

No Coverage

Complex Imaging (MRI, PET, and CT scans)

80%

No Coverage

Urgent Care

80%

No Coverage

Hospital Services

80%

No Coverage

Emergency Room Services

80%

Paid Same as in-network

Prescription Drug Services (Administered through CVS/Caremark)

Non-Preferred Brand 80% Coinsurance after deductible

Generic

Brand

80% Coinsurance after deductible

80% Coinsurance after deductible

30-day supply

80% Coinsurance after deductible

80% Coinsurance after deductible

80% Coinsurance after deductible

90-day supply

Lifetime Maximum

Unlimited

*Please note - Allied is your plan administrator. Cigna is your medical provider network. Physicians should confirm benefits & eligibility with Allied (instructions on your ID card).

2022 Benefits Guide

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