Allowance Maximums

Allowance maximums mean that if you elect to have a MAMMOGRAM or COLONOSCOPY that is more than the allowance, you will be responsible for covering the remaining cost. This remaining cost will not apply to your annual deductible or out-of-pocket maximum.

For MRIs and CT Scans, once you have met your deductible, the plan will pay 80% per procedure up to the allowed amount, then you will be responsible for any remaining cost.

  • Preventive Mammogram: $225
  • Preventive Mammogram-3D: $285
  • Preventive Colonoscopy: $2,250
  • All MRIs: $2,300 (After deductible is met)
  • CT Scans: $2,000 (After deductible is met)
Preventive Mammogram Example

Cost for Preventive Mammogram: $272
Plan Pays:  $225
Your Responsibility: $47

CT Scan Example

Cost for CT Scan: $2,210
Plan Pays:  $1,600 (80% of allowable amount of $2,000)
Your Responsibility: $400 + $210 = $610 (20% Coinsurance + Amount above the allowance)

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*Allowances are based on national average costs for these diagnostic services.

Cigna
1-855-566-4295
WebTPA
1-844-380-4564
Express Scripts
1-877-887-2879
Cigna MDlive
1-855-818-3627
Metlife
1-855-488-0520
Aflac
1-800-433-3036
The Hartford
1-800-445-9057
TaxSaver Plan
1-888-602-6272
Fidelity
1-800-835-5087
One America
1-855-279-6375