Covered Benefits: Outpatient Services
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Plan's Coinsurance Percentage for In-Network Care
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Plan's Coinsurance Percentage for Out-of-Network Care*
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Outpatient Services
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Acupuncture Services
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80% coverage after deductible
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50% coverage after deductible
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Cognitive Rehabilitation Therapy
(combined in-network and out-of-network limit of 60 visits/calendar year)
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80% coverage after deductible
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50% coverage after deductible
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Convenience Care Clinics
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90% coverage before deductible
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50% coverage after deductible
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Home Health Care
(may require precertification; limited to maximum of 200 visits/calendar year; one visit = four hours)
See "Mental Health Benefits" for more information.
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80% coverage after deductible
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50% coverage after deductible
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Infertility Services
(available to covered members with a medical diagnosis of infertility, as defined by your health care company)
Limited to combined in-network and out-of-network maximum of $10,000/lifetime for each covered member**
($30,000 lifetime maximum if you contact WIN Fertility and complete a nurse consultation described under "Infertility Treatment Procedures")
Separate $10,000 prescription drug benefit; see "What's Covered and Not Covered."
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80% coverage after deductible; coverage requires you to contact your health care company and receive precertification before obtaining services
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50% coverage after deductible; coverage requires you to contact your health care company and receive precertification before obtaining services
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Mental Health Care
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80% coverage after deductible
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50% coverage after deductible
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Primary Care Office Visits (to family practitioners, internists, pediatricians, OB/GYNs, and convenience care clinics).
Internists must be contracted with Aetna or Cigna as a Primary Care Physician (PCP). Go to Aetna or Cigna's websites through My Health to search for PCPs/primary care.
(includes tests, injection drugs, supplies, and other services authorized by the Plan and provided during the visit and billed by the Primary Care Physician)
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90% coverage before deductible
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50% coverage after deductible
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Routine eye exams
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Not covered
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Not covered
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Specialist's Office Visits
(includes tests, injection drugs, supplies, and other services authorized by the Plan and provided during the visit, consultations, specialist referrals, and second surgical opinions)
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80% coverage after deductible
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50% coverage after deductible
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Speech, Physical, or Occupational Therapy
(combined in-network and out-of-network limit of 60 visits/calendar year per therapy type**; unlimited for those with a mental health diagnosis)
See "Mental Health Benefits" for more information.
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80% coverage after deductible
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50% coverage after deductible
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Spinal Treatment/Chiropractic Care
(coverage ends when medical recovery is achieved, and treatment is for maintenance or managing pain; limited to 20 visits/calendar year including initial consultation**
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80% coverage after deductible
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50% coverage after deductible
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Substance Use Disorder Services
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80% coverage after deductible
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50% coverage after deductible
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Urgent Care Center
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80% coverage after deductible
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80% coverage after the deductible
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Virtual Doctor Visit
for medical (non-mental health) services delivered through Teladoc (Aetna) and MDLive (Cigna)
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Approximately $5 (90% coverage) before deductible for primary care services. Mental health services are covered at 80% after the deductible.
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Not covered
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* Covered out-of-network expenses are subject to reasonable and customary (R&C) charges. You are responsible for paying any charges above the R&C amount.
** Combined in-network and out-of-network. All out-of-network expenses are subject to reasonable and customary (R&C) charges. You are responsible for paying any charges above the R&C amount. Since in-network charges for covered services have been negotiated with the providers, those charges would always be within the R&C limits.