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, Cigna 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.