JR Davis Construction Health Benefit Plan — Base Plan: Medical Schedule of Benefits
This document is the Medical Schedule of Benefits for the JR Davis Construction Health Benefit Plan (Base Plan), effective April 1, 2026. It outlines coverage details for members using Cigna PPO Network providers and Non-PPO providers, including calendar year deductibles, coinsurance rates, out-of-pocket maximums, copayment amounts, prescription drug benefits, and service-specific coverage rules. Members should refer to the Medical Plan Document and Summary Plan Description for full details of coverage.
Effective April 1, 2026
Document Link : Visit the document here
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Table of Contents
- Deductibles
- Plan Coinsurance
- Out-of-Pocket Maximum
- Lifetime Maximum Benefit
- Medical Benefits — Covered Services
- Pre-certification Requirements
- Prescription Drug Benefits
- Routine & Preventive Care
- Contact Information
1. Member Calendar Year Deductible
PPO and Non-PPO deductibles do not combine.
| Deductible Type | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Medical Plan Deductible — Individual | $4,000 | $10,000 |
| Medical Plan Deductible — Family | $8,000 | $30,000 |
| Prescription Drug Deductible — Individual | $300 | — |
| Prescription Drug Deductible — Family | $300 | — |
Notes:
- The Calendar Year deductible does NOT include pre-certification penalties, non-covered expenses, or charges in excess of Reasonable & Allowed charges.
- If enrolled for family coverage, each family member must meet their own individual deductible until the overall family deductible has been met.
2. Plan Coinsurance
| Cigna PPO Network Providers | Non-PPO Providers | |
|---|---|---|
| Coinsurance | Plan pays 70% of covered expenses | Plan pays 50% of Reasonable & Allowed Amount |
3. Member Out-of-Pocket Maximum
PPO and Non-PPO Out-of-Pocket maximums do not combine.
| Cigna PPO Network Providers | Non-PPO Providers | |
|---|---|---|
| Individual | $6,000 | $20,000 |
| Family | $12,000 | $40,000 |
Notes:
- The Out-of-Pocket Maximum includes Medical & Prescription Drug Calendar Year deductibles, Member Coinsurance, Medical & Prescription Drug Co-payments.
- Pre-certification penalties, non-covered expenses, and charges in excess of Reasonable & Customary charges do not accumulate towards the Out-of-Pocket Maximum.
- If enrolled for family coverage, each family member must meet their own individual Out-of-Pocket maximum until the overall family Out-of-Pocket maximum has been met.
4. Lifetime Maximum Benefit
| Benefit | |
|---|---|
| Lifetime Maximum | Unlimited |
5. Medical Benefits — Covered Services
5.1 Alcohol & Substance Abuse Treatment
Pre-certification is required for Inpatient admissions and Partial Hospitalization / Intensive Outpatient Treatment.
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Office Visit | $30 Co-payment; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Hospital Clinic Visit | 70% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Partial Hospitalization / Intensive Outpatient Treatment | 100% of covered expenses; not subject to Calendar Year deductible. Includes Physician visits. | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Inpatient Hospitalization | 70% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
5.2 Allergy Injections & Testing
Includes office visits & serum.
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Allergy Injections & Testing | $30 Co-payment per visit; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
5.3 Ambulance Services
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Ambulance Services | 70% Coinsurance; subject to In-Network Calendar Year deductible | 70% Coinsurance; subject to In-Network Calendar Year deductible |
Note: Limitations apply, refer to Plan for details.
5.4 Autism Spectrum Disorders Treatment
Pre-certification is required for ABA; limitations apply.
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Autism Spectrum Disorders Treatment | Benefits are based on services provided | Benefits are based on services provided |
Notes:
- Benefit limits do not apply to occupational, physical, and speech therapies for treatment of autism spectrum disorders.
- Includes habilitative and rehabilitative care, Applied Behavior Analysis (ABA), pharmacy care, psychiatric care, psychological care, therapeutic care, and social work services.
5.5 Birthing Center
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Birthing Center | 70% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
5.6 Cardiac Rehabilitation
Phase 1 & 2 only.
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Cardiac Rehabilitation | $55 Co-payment; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
5.7 Chemotherapy & Radiation Therapy
Requires Pre-certification.
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Chemotherapy & Radiation Therapy | 70% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
5.8 Chiropractic Services / Spinal Manipulation
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Chiropractic Services / Spinal Manipulation | $55 Co-payment; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
Note: Limited to 26 visits per Calendar Year.
5.9 Clinical Trials
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Clinical Trials | Benefits are based on services provided | Benefits are based on services provided |
Note: Includes routine services during Approved Clinical Trials. Limited to routine Covered Services under the Plan, including Hospital visits, laboratory, and imaging services.
5.10 Dental / Oral Services
Excludes excision of impacted wisdom teeth.
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Dental / Oral Services | 70% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
5.11 Diabetes Self-Management Training & Education
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Diabetes Self-Management Training & Education | 70% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
5.12 Dialysis / Hemodialysis
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Dialysis / Hemodialysis | 70% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
5.13 Durable Medical Equipment
Pre-certification is required.
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Durable Medical Equipment | 70% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
Note: Pre-certification is required for insulin pumps and supplies, and equipment in excess of $2,500 and for Out-of-Network providers.
5.14 Early Intervention Services
Up to age 3.
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Early Intervention Services | $30 Co-payment; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
5.15 Emergency Room Services
Includes Facility, Lab, X-ray & Physician services.
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Emergency Room Services | 70% Coinsurance; subject to Calendar Year deductible | Emergency Care: 70% Coinsurance; subject to In-Network Calendar Year deductible |
| Non-Emergency Care: 50% Coinsurance; subject to Calendar Year deductible |
5.16 Family Planning
Including but not limited to voluntary sterilization, consultations & diagnostic tests.
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| For Women | 100% of covered expenses; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| For Men | 70% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
5.17 Genetic Counseling, Testing & Related Services
Pre-certification is required.
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Genetic Counseling, Testing & Related Services | 70% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
Note: Pre-certification is not required for BRCA Testing.
5.18 Home Health Care
Pre-certification is required.
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Home Health Care | 70% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
Note: Limited to 20 visits per Calendar Year.
5.19 Hospice Care
Includes Inpatient & Outpatient Hospice Care.
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Hospice Care | 70% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
Note: Pre-certification is required for inpatient Hospice admissions.
5.20 Hospital Services (Inpatient)
All Inpatient Hospital admissions require Pre-certification.
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Hospital Services (Inpatient) | 70% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
5.21 Hospital Services (Outpatient)
Refer to Pre-certification requirements.
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Clinic Services | 70% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Outpatient Department | 70% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Pre-admission Testing | 70% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Outpatient Surgery in Hospital / Ambulatory Surgical Center | 70% Coinsurance; subject to Calendar Year deductible (Pre-certification required) | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
5.22 Injectables
Pre-certification is required for injectables in excess of $1,500.
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Injectables | 70% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
5.23 Learning Deficiencies, Behavioral Problems & Developmental Delays
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Learning Deficiencies, Behavioral Problems & Developmental Delays | $30 Co-payment per visit; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
5.24 Maternity Care
Refer to Newborn Care for newborn benefits. Refer to Birthing Center for benefits, if applicable.
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Physician delivery charges, prenatal/postpartum care, including planned home births | 100% of covered expenses; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Inpatient Hospital charges | 70% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
5.25 Medical & Enteral Formula
Requires Pre-certification. Includes metabolic formula.
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Medical & Enteral Formula | 70% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
5.26 Mental Health Services
Pre-certification is required for Inpatient admissions and Partial Hospitalization / Intensive Outpatient Treatment.
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Office Visit | $30 Co-payment; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Hospital Clinic Visit | 70% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Partial Hospitalization / Intensive Outpatient Treatment | 100% of covered expenses; not subject to Calendar Year deductible. Includes Physician visits. | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Inpatient Hospitalization | 70% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
5.27 Newborn Care
Includes Physician visits & circumcision.
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Newborn Care | 70% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
5.28 Orthotics
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Orthotics | 70% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
Notes:
- Includes foot orthotics.
- Pre-certification is required for helmets and knee braces.
5.29 Outpatient Imaging
Includes MRI, CT & PET Scans. Pre-certification is required.
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Outpatient Imaging | 70% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
Note: Please contact Karias Health prior to imaging to determine if you are eligible for a $0 Co-payment.
5.30 Outpatient X-Ray & Laboratory Services
Outpatient Hospital & Independent Facility.
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Diagnostic X-Rays | 70% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Laboratory (Independent Facility) | $0 Co-payment; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Laboratory (Outpatient Facility Based) | $50 Co-payment; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| All other diagnostic tests | 70% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
5.31 Outpatient Therapy Services
Requires Pre-certification after 13 visits.
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Outpatient Therapy Services | $55 Co-payment per visit; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
Note: Combined Outpatient Therapy maximum benefit of 25 visits for Physical Therapy, Speech Therapy, and Occupational Therapy due to Illness or Injury.
5.32 Physician Hospital Visits
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Physician Hospital Visits | 70% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
5.33 Physician Office Visits
Includes all related charges billed at time of visit. Pre-certification is required for on-going wound care.
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Teladoc Virtual Visit | $0 Co-payment | — |
| Primary Care | $30 Co-payment; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Specialist | $55 Co-payment; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Urgent Care Facility / Walk-in Clinic | $60 Co-payment; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Virtual Provider Visits | Paid based on services provided | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
5.34 Podiatry Care
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Podiatry Care | $55 Co-payment per visit; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
5.35 Prosthetic Appliances
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Prosthetic Appliances | 70% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
Note: Refer to Durable Medical Equipment benefit for Pre-certification requirements.
5.36 Respiratory Therapy
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Respiratory Therapy | $55 Co-payment per visit; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
5.37 Second Surgical Opinion
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Primary Care | $30 Co-payment; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Specialist | $55 Co-payment; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
5.38 Skilled Nursing Facility, Extended Care Facility & Rehabilitation Hospital
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Skilled Nursing Facility, Extended Care Facility & Rehabilitation Hospital | 70% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
Notes:
- Requires Pre-certification.
- Combined Calendar Year maximum benefit of 60 days.
5.39 Surgical Procedures
Pre-certification is required for Outpatient surgery in a Hospital or Ambulatory Surgical Center.
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Inpatient Hospital Surgery | 70% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Outpatient Hospital / Ambulatory Surgical Center | 70% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| PCP Office | Included in $30 office visit Co-payment | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
| Specialist Office | Included in $55 office visit Co-payment | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
5.40 Temporomandibular Joint Disorders (TMJ) Treatment
Requires Pre-certification.
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| TMJ Treatment | 70% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
5.41 Transplant Benefits
Requires Pre-certification.
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Transplant Benefits | 70% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
Notes:
- Managed through Cigna's LifeSOURCE Transplant Network.
- Includes transportation, food & lodging expenses to a maximum benefit of $10,000 per transplant procedure.
5.42 Urgent Care Facility & Walk-in Clinic
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Urgent Care Facility & Walk-in Clinic | $60 Co-payment; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
5.43 All Other Covered Medical Expenses
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| All Other Covered Medical Expenses | 70% Coinsurance; subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
6. Pre-certification Requirements
Failure to comply with the Pre-certification requirements of the Plan will result in a $750 reduction of benefits due to pre-certification non-compliance.
Pre-admission certification is mandatory for all inpatient & outpatient facility-based services. This includes all hospital admissions and all services at a hospital, surgical center, outpatient facility, or dialysis center. Emergency hospital admissions must be approved within 48 hours.
Services requiring Pre-certification:
| Service |
|---|
| All Inpatient Hospital Admissions |
| All Outpatient Hospital Based Services |
| Applied Behavior Analysis (ABA) Therapy |
| Chemotherapy & Radiation Therapy |
| DME in excess of $2,500 and DME from Out-of-Network Providers |
| Genetic Counseling, Testing & Related Services |
| Helmets & Knee Braces (orthotics) |
| Home Health Care |
| Inpatient Hospice Care |
| Injectables in excess of $1,500 |
| Medical & Enteral Formula |
| Outpatient Imaging |
| Outpatient Therapy Services after 13 visits |
| On-going wound care |
7. Prescription Drug Benefits
Prescription Drug Calendar Year Deductible: $300 per Individual / $300 per Family
Notes:
- Tobacco cessation products are covered at 100%; Deductible waived.
- Preventive Care drugs are not subject to the Prescription Drug Deductible.
- Prescriptions purchased from Out-of-Network Pharmacies are not eligible for reimbursement by the Plan.
- See Covered Services section for coverage requirements related to specialty drugs.
7.1 Retail Pharmacy Program (30-day supply maximum)
| Drug Tier | Co-pay | Deductible |
|---|---|---|
| Generic drugs | $10 Co-pay | Deductible waived |
| Preferred Brand drugs | $60 Co-pay | After Prescription Drug Calendar Year deductible |
| Non-Preferred Brand drugs | $100 Co-pay | After Prescription Drug Calendar Year deductible |
7.2 Retail Maintenance Pharmacy Program (90-day supply maximum)
| Drug Tier | Co-pay | Deductible |
|---|---|---|
| Generic drugs | $25 Co-pay | Deductible waived |
| Preferred Brand drugs | $150 Co-pay | After Prescription Drug Calendar Year deductible |
| Non-Preferred Brand drugs | $250 Co-pay | After Prescription Drug Calendar Year deductible |
7.3 Mail Order Pharmacy (90-day supply maximum)
| Drug Tier | Co-pay | Deductible |
|---|---|---|
| Generic drugs | $25 Co-pay | Deductible waived |
| Preferred Brand drugs | $150 Co-pay | After Prescription Drug Calendar Year deductible |
| Non-Preferred Brand drugs | $250 Co-pay | After Prescription Drug Calendar Year deductible |
7.4 Specialty Drugs — Retail & Mail Order (30-day supply maximum)
| Drug Tier | Co-pay | Deductible |
|---|---|---|
| Generic drugs | $25 Co-pay | Deductible waived |
| Preferred Brand drugs | $150 Co-pay | After Prescription Drug Calendar Year deductible |
| Non-Preferred Brand drugs | $250 Co-pay | After Prescription Drug Calendar Year deductible |
8. Routine & Preventive Care
8.1 Routine Colonoscopy
Age/frequency limitations apply.
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Routine Colonoscopy | 100% of covered expenses; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
8.2 Routine Mammogram
Age/frequency limitations apply.
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Routine Mammogram | 100% of covered expenses; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
8.3 Routine Well Adult Care (Age 18 and above)
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Routine Well Adult Care | 100% of covered expenses; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
This routine benefit includes, but is not limited to, physician charges for an annual routine examination, routine x-rays and laboratory, immunizations, and the following routine services:
| Covered Routine Services |
|---|
| Immunizations |
| Fasting lipoprotein profile (cholesterol screening) |
| Annual Prostate Specific Antigen (PSA) screening |
| Tobacco use screening and cessation interventions |
| Fasting blood sugar screening (for diabetes mellitus) |
| Blood pressure screening |
| Obesity screening and counseling |
| Annual colorectal screening |
| BRCA genetic counseling and testing |
| Statin preventive medication |
| Bone Mineral Density (BMD) screening (once every 24 months) |
| Women's Health Services: pelvic exam & Pap test; screening for gestational diabetes; DNA Testing; HPV (Human Papillomavirus); counseling for sexually transmitted infections; counseling & screening for human immunodeficiency virus; screening & counseling for interpersonal and domestic violence; breastfeeding support & supplies; sterilization; and contraceptive methods & counseling. Limitations may apply. |
A complete list of covered ACA mandated routine services for women/adults is available at: https://www.healthcare.gov/coverage/preventive-care-benefits/
8.4 Routine Well Child Care (Birth through age 17)
| Service | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Routine Well Child Care | 100% of covered expenses; not subject to Calendar Year deductible | 50% of Reasonable & Allowed amount; subject to Calendar Year deductible |
Includes: Office Visit charges, immunizations, laboratory blood tests, developmental screening, behavioral assessments, routine vision screening & hearing screening for newborns.
A complete list of covered ACA mandated routine services for children is available at: https://www.healthcare.gov/coverage/preventive-care-benefits/
9. Contact Information
| Resource | Details |
|---|---|
| Claims Administrator | Preferred Benefit Administrators |
| Address | PO Box 916188, Longwood, FL 32791-6188 |
| Phone | 407-786-2777 or 888-524-2777 |
| Website | www.PreferredTPA.com |
| Member Concierge Care | Karias Health |
| Phone | 888-832-0354 |
| Website | www.kariashealth.com |
| Locate Cigna PPO Providers | www.Cigna.com |