Page 31 - 2021-2022 New Hire Benefits

Screenings In-network member pays Out-of-network member pays

Baseline routine 0% coinsurance 30% coinsurance
mammography after plan deductible after plan deductible
(ages 35-39)
Annual routine mammography No charge 30% coinsurance
(age 40 or older) after plan deductible
30% coinsurance
Annual routine vision exam No charge
after plan deductible
Allergy testing Refer to your applicable primary 30% coinsurance
Unlimited care or specialist cost share after plan deductible

Ongoing Care and Sick Visits In-network member pays Out-of-network member pays
$30 copayment/visit 30% coinsurance
Primary care services
after plan deductible after plan deductible
$45 copayment/visit 30% coinsurance
Specialist services
after plan deductible after plan deductible
$30 copayment/visit 30% coinsurance
Gynecologist services
after plan deductible after plan deductible
Maternity and prenatal care
visits 30% 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 30% coinsurance
Unlimited care or specialist cost share after plan deductible
Refer to your applicable primary 30% coinsurance
Telemedicine visit
care or specialist cost share after plan deductible
$30 copayment/visit 30% coinsurance
Retail clinic
after plan deductible after plan deductible
Lab and Radiology
Performed in a hospital, lab or In-network member pays Out-of-network member pays
radiology facility
0% coinsurance 30% coinsurance
Laboratory services
after plan deductible after plan deductible
Non-advanced radiology 0% coinsurance 30% coinsurance
X-ray, diagnostic after plan deductible after plan deductible

Advanced radiology
Hospital facility 0% coinsurance 30% coinsurance
MRI, PET and CAT scan and after plan deductible after plan deductible
nuclear cardiology

Advanced radiology
Stand-alone facility 0% coinsurance 30% coinsurance
MRI, PET and CAT scan and after plan deductible after plan deductible
nuclear cardiology

CICI Flex and Combined/BS LG (01/2021) E ective Date: 7/2021
FlexPOS-CNT-HS129631
CT P01654141/P01654142 / MA P01754144/P01754143 -129631
FlexPOS-CNT-HSA-2000I/4000F-30-45-08
Bene t ID: LS/LT