Important Questions
Answers
Why This Matters:
This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. You can see the specialist you choose without a referral.
Will you pay less if you use a network provider?
Yes. See www.cigna.com or call 1-800-Cigna24 for a list of network providers.
Do you need a referral to see a specialist?
No.
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. What You Will Pay Common Medical Event Services You May Need In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most)
Limitations, Exceptions, & Other Important Information
Primary care visit to treat an injury or illness
$30 copay/visit Deductible does not apply $40 copay/visit Deductible does not apply No charge/visit** No charge/screening** No charge/immunizations**
50% coinsurance
None
Specialist visit
50% coinsurance Not covered/visit
None None None None
If you visit a health care provider's office or clinic
Not covered/screening Not covered/immunizations
Preventive care/ screening/ immunization
You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.
**Deductible does not apply
Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs)
20% coinsurance
50% coinsurance
None
If you have a test
50% penalty for no out-of-network precertification.
20% coinsurance
50% coinsurance
2 of 9
Made with FlippingBook HTML5