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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