Page 19 - 2021-2022 New Hire Benefits
P. 19
Screenings In-network member pays Out-of-network member pays
Allergy testing Refer to your applicable primary 20% coinsurance
Unlimited care or specialist cost share after plan deductible
Ongoing Care and Sick Visits In-network member pays Out-of-network member pays
20% coinsurance
Primary care services $30 copayment/visit
after plan deductible
20% coinsurance
Specialist services $45 copayment/visit
after plan deductible
20% coinsurance
Gynecologist services $30 copayment/visit
after plan deductible
Maternity and prenatal care
visits 20% coinsurance
May not apply to all laboratory and No charge after plan deductible
radiology services – refer to your
plan documents
Allergy injections Refer to your applicable primary 20% coinsurance
Unlimited care or specialist cost share after plan deductible
Refer to your applicable primary 20% coinsurance
Telemedicine visit
care or specialist cost share after plan deductible
20% coinsurance
Retail clinic $30 copayment/visit
after plan deductible
Lab and Radiology
Performed in a hospital, lab or In-network member pays Out-of-network member pays
radiology facility
20% coinsurance
Laboratory services No charge
after plan deductible
Non-advanced radiology 20% coinsurance
X-ray, diagnostic No charge after plan deductible
Advanced radiology
Hospital facility No charge 20% coinsurance
MRI, PET and CAT scan and after plan deductible
nuclear cardiology
Advanced radiology
Stand-alone facility No charge 20% coinsurance
MRI, PET and CAT scan and after plan deductible
nuclear cardiology
Sudden and Unexpected Care In-network member pays Out-of-network member pays
Urgent care or other walk-in $50 copayment/visit Same as In-network bene t
clinic
Emergency room $300 copayment/visit Same as In-network bene t
copayment waived if admitted
Ambulance No charge Same as In-network bene t
CICI FlexPOS and Combined/BS LG (01/2021) E ective Date: 7/2021
FlexPOS-CNT-30129705
CT P01656449 / MA P01756450 -129705
FlexPOS-CNT-30-45-300-500D-01
Bene t ID: Lo
