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
$0Just You
$1,000Just You
Deductible per Calendar Year
$0You + Family
$2,000You + Family
$2,500Just You
$2,500Just You
Out-of-Pocket Maximum per Calendar Year
$5,000You + Family
$5,000You + Family
Coinsurance
100%
70%
Physician Services
Annual Preventive Care Visit
100%, deductible waived
70%
Physician Office Visit
$15 Copay, deductible waived
70%
Specialist Office Visit
$30 Copay, deductible waived
70%
Physical & Occupational Therapy - maximum visits per year: 90 Speech Therapy - maximum visits per year: 90 Chiropractic Therapy - maximum visits per year: 90
$30 Copay, deductible waived
70%
$30 Copay, deductible waived
70%
$30 Copay, deductible waived
70%
X-Rays / Lab Diagnostics
100%
70%
Complex Imaging (MRI, PET, and CT scans)
100%
70%
Urgent Care
$30 Copay, deductible waived
70%
Hospital Services
$500 Copay, deductible waived
70%
Emergency Room Services
$100 Copay, deductible waived
Paid Same as in-network
Prescription Drug Services (Administered through CVS/Caremark)
Non-Preferred Brand
Generic
Brand
30-day supply
$15 Copay
$25 Copay
$75 Copay
90-day supply
$37.50 Copay
$62.50 Copay
$187.50 Copay
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).
10
2023 Benefits Guide
Made with FlippingBook Digital Proposal Creator