CIGNA Open Access Plan
	In-Network	Out-of-Network
Annual Deductible Amount for injury, illness, or maternity	$300 / individual $600 / family	$500 / individual $1,000 / family
Out-of-Pocket Annual Limit (excludes deductible)	$1,500 / individual $3,000 / family	$4,500 / individual $9,000 / family
Pre-Existing Conditions	n/a	n/a
Maximum Lifetime Benefit (in-network and out-of-network combined)	$2,000,000	$2,000,000
Services Covered	In-Network	Out-of-Network*
Outpatient Short-Term Rehabilitation – 180 visits per year for all conditions, in-network and out-of-network combined. Includes speech, occupational, physical and cardiac therapy	Covered 100%	Covered 60% of R&C* after deductible
Outpatient laboratory and X-ray: All charges billed by an independent facility.	Covered 100%	Covered 60% of R&C* after deductible
Home Health Care (skilled visits only) Maximum number of hours per day is limited to 16 hours. Multiple visits can occur in one day; with a visit defined as a period of 2 hours or less.	Covered 100%; unlimited days	Covered 60% of R&C* after deductible for up to 60 days per calendar year, reduced by any in-network days
Durable Medical Equipment	Covered 100%	Covered 60% of R&C* after deductible
External Prosthetic Devices – Requires approval by Health Plan	Covered 90% after deductible and $100 copayment per appliance	Covered 60% of R&C* after deductible
Hospital Care
Services Covered	In-Network	Out-of-Network*
Inpatient Services: semi-private room, operating room, X-ray, and laboratory services. Includes stand-alone facilities such as Birthing Center.	Covered 90% after deductible and $250 copayment per admission	Covered 60% of R&C* after deductible and $500 copayment per admission
Outpatient Services: Outpatient surgery	Covered 90% after deductible and $150 copayment per visit	Covered 60% of R&C* after deductible and $300 copayment per visit
Transplant Coverage:  Inpatient Facility	Covered 90% after deductible and $250 copayment at approved facilities	Covered 60% of R&C* after deductible and $500 copayment per admission
Travel Benefit	$10,000 per transplant per lifetime when using an approved facility	Not covered
Emergency Room Services (not covered if not a true Emergency)	Covered 100% after $100 copayment per visit if true emergency (waived if admitted)	Covered 100% after $100 copayment per visit if true emergency (waived if admitted)
Ambulance Services (not covered if not a true Emergency)	Covered 100%	Covered 100%
Urgent Care Facility (not covered if not a true Emergency)	Covered 100% after $50 copayment	Covered 100% after $50 copayment
Inpatient Mental Health – 20 days per calendar year in- network and out-of-network combined	Covered 90% after deductible and $250 copayment per admission	Covered 60% of R&C* after deductible and $500 copayment per admission
Inpatient Alcohol and Drug Abuse – two admissions per lifetime and 100 days per lifetime, in-network and out-of-network combined	Covered 90% after deductible and $250 copayment per admission	Covered 60% of R&C* after deductible and $500 copayment per admission
Maternity – Inpatient	Covered 90% after deductible and $250 copayment per admission	Covered 60% of R&C* after deductible and $500 copayment per admission
Inpatient Services at other healthcare facilities: Includes Skilled Nursing Facility, Rehabilitation Hospital and Subacute facilities 60 days per calendar year for in-network and out-of-network combined	Covered 90% after deductible	Covered 60% of R&C*
Hospice Care Inpatient	Covered 90% after deductible and $250 copayment per admission	Covered 60% of R&C*after deductible and $500 copayment per admission
Outpatient	Covered 100%, no copayment	Covered 60% of R&C* after deductible
Physician Care
Services Covered	In-Network	Out-of-Network*
Primary Care Office Visit	Covered 100% after $15 copayment	Covered 60% of R&C* after deductible
Specialist Office Visit	Covered 100% after $30 copayment	Covered 60% of R&C* after deductible
Vision Exam Services Provided by VSP	No charge for yearly exam; no charge for standard frames every 24 months; no charge for standard lenses every 12 months; or reimbursement up to $75 for one pair of contact lenses (replaces all other benefits and includes exam)	Plan covers up to $25 toward yearly exam; up to $40 toward pair of frames every 24 months; lenses according to fee schedule or one pair of contact lenses every 12 months up to $75 (replaces all other benefits and includes exam)
Physician and Surgeon Services in Hospital	Covered 90% after plan deductible	Covered 60% of R&C* after deductible
Maternity Office Visits	Covered 100% after one-time office visit copayment	Covered 60% of R&C* after deductible
Maternity Delivery (Physician charges)	Covered 90% after plan deductible	Covered 60% of R&C* after deductible
Preventive Health Services:
Well-Baby Care	Covered 100% after $15 copayment (includes immunizations)	Not covered
Routine Physical Exam	Covered 100% after $15 primary care office copayment	Not covered
Routine Gynecological Exams	Covered 100% after $15 physician’s office copayment if physician used is contracted as primary care physician	Not covered
Routine Mammogram	Covered at 100% (no referral needed)	Covered 60% of R&C* after deductible
Hearing Aid Benefits	Covered at 100%; $750 maximum every 36 months	Hearing aid not covered
Hearing Exam	Covered at 100% after $30 copayment per visit	Exam covered 60% after deductible
Chiropractic Care	Covered 100% after $30 copayment; 25 visit limit per year	Not covered
Substance Abuse – Outpatient	$30 copayment per visit for individual therapy; unlimited visits $15 copayment per visit for group therapy; unlimited visits	Covered 60% R&C* after deductible; up to 35 visits per year, reduced by any in-network visits
Mental Health – Outpatient	$30 copayment per visit for individual therapy; unlimited visits $15 copayment per visit for group therapy; unlimited visits	Covered 60% of R&C* after deductible; up to 35 visits per year, reduced by any in-network visits
Physician Services in Emergency Room	Covered 100%	Covered 100%
Infertility Treatment:	Limited coverage; $20,000 lifetime maximum	Limited coverage; $20,000 lifetime maximum
Prescription Drugs, administered by Medco
Services Covered	In-Network	Out-of-Network*
Retail Prescription Drugs (Up to a 30-day supply)	$150 deductible Generic: 20% (minimum $10 copayment) after deductible Brand: 30% (minimum $10 copayment) after deductible If actual cost is under $10, then you pay actual cost	50% of cost after $150 deductible
Mail Order – Home Delivery (Up to a 90-day supply)	Generic: $15 copayment Brand: $35 copayment	Not covered

*R&C — Reasonable and Customary Charges