Page 39 - Benefits Summary 2018-2019

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
Will you pay less if you use a Yes. See www.myCigna.com or call 1-866-494-2111 between the provider’s charge and what your plan pays (balance billing).
network provider? for a list of network providers.
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.

Do you need a referral to see
a specialist? No. You can see the specialist you choose without a referral.

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 Services You May Need Limitations, Exceptions, & Other

Medical Event In-Network Provider Out-of-Network Provider Important Information
(You will pay the least) (You will pay the most)

Primary care visit to treat an $30 copay/visit
injury or illness Deductible does not apply 30% coinsurance None

$50 copay/visit
Specialist visit 30% coinsurance None
Deductible does not apply
If you visit a health care No charge/visit** 30% coinsurance/visit You may have to pay for services that

provider's office or clinic No charge/other services** 30% coinsurance/other aren’t preventive. Ask your provider if
Preventive care/ services the services you need are preventive.

screening/immunization No charge/immunizations** 30% coinsurance/ Then check what your plan will pay
immunizations for.
**Deductible does not apply

Diagnostic test (x-ray, blood No charge 30% coinsurance None
work) Deductible does not apply

$150 copay/scan at an
If you have a test 30% coinsurance at an
Imaging (CT/PET scans, outpatient facility** outpatient facility $250 penalty for no precertification.

MRIs) $150 copay/scan in the office** 30% coinsurance in the office
**Deductible does not apply

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