Medical Benefits

Your employer offers medical insurance to protect the health of you and your family. It covers medical expenses such as visits to the doctor’s office, emergency care, and prescription drugs. It’s important to have a medical plan that meets your needs and the needs of your family.

Keep in mind that your out-of-pocket costs will be lower if you receive care from an in-network doctor and facility. To find an in-network doctor, please visit www.cigna.com or https://www.askallegiance.com/.

	In-Network	Out-of-Network
Calendar Year Deductible (Individual/Family)	$1,500/$4,500	$2,000/$6,000
Calendar Year Out-of-Pocket Max (Individual/Family)	$3,000/$9,000	$4,000/$12,000
Member Coinsurance	70%/30%	50%/50%
Physician Visits
Primary Care	$25 Copay	Deductible + 50%
Preventive Care	Fully covered	Deductible + 50%
Specialist	$35 Copay	Deductible + 50%
Hospital Services
Physician Services	Deductible + 30%	Deductible + 50%
Inpatient Hospitalization	Deductible + 30%	Deductible + 50%
Outpatient Surgery	Deductible + 30%	Deductible + 50%
Basic Outpatient Diagnostics	Deductible + 30%	Deductible + 50%
Urgent Care	$50 Copay	Deductible + 50%
Emergency Room	$200 Copay, then Deductible + 30%	$200 Copay, then Deductible + 30%

Prescription Drugs
Pharmacy Out-of-Pocket Max (Individual/Family)	$3,600/$4,200
Retail Prescriptions
Generic	$15
Preferred Brand	$45
Non-preferred Brand	$65
Mail Order Drugs
Generic	$30
Preferred Brand	$100
Non-preferred Brand	$150

	Per Pay Period Cost
Employee Only	$79.00
Employee + Spouse/Domestic Partner	$295.00
Employee + Child(ren)	$234.00
Employee + Family	$367.00

Downloads

Summary of Benefits

MDLIVE Welcome Flyer

MDLIVE Virtual Care

MDLIVE Behavior Health Flyer

	In-Network	Out-of-Network
Calendar Year Deductible (Individual/Family)	$500 / $1,500	$1,000/$3,000
Calendar Year Out-of-Pocket Max (Individual/Family)	$2,000/$6,000	$4,000/$12,000
Member Coinsurance	90% / 10%	60% / 40%
Physician Visits
Primary Care Visit	$15 Copay	Deductible + 40%
Preventive Care	Fully covered	Deductible + 40%
Specialist Visit	$25 Copay	Deductible + 40%
Hospital Services
Physician Services	Deductible + 10%	Deductible + 40%
Inpatient Hospitalization	Deductible + 10%	Deductible + 40%
Outpatient Surgery	Deductible + 10%	Deductible + 40%
Basic Outpatient Diagnostics	Deductible + 10%	Deductible + 40%
Urgent Care	$25 Copay	Deductible + 40%
Emergency Room	$200 Copay, then Deductible + 10%	$200 Copay, then Deductible + 10%

Prescription Drugs
Pharmacy Out-of-Pocket Max	$3,600/$4,200
Retail Prescriptions
Generic	$12
Preferred Brand	$40
Non-preferred Brand	$60
Mail Order Drugs
Generic	$30
Preferred Brand	$100
Non-preferred Brand	$150