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Limitations & Exceptions -----------none----------- $750 penalty for no precertification. $750 penalty for no precertification. Coverage is limited to 90 days annual max. Maximums cross-accumulate. $750 penalty for failure to precertify speech therapy services. Coverage is limited to annual max of: 30 days per therapy type for Physical, Speech, Occupational and Cognitive therapies; Unlimited days for Cardiac, Pulmonary & Respiratory rehab. -----------n
Out-of-Network Provider 40% co-insurance 40% co-insurance 40% co-insurance 40% co-insurance Not Covered 40% co-insurance 40% co-insurance 40% co-insurance Not Covered Not Covered Not Covered
Your Cost if you use an
In-Network Provider 20% co-insurance 20% co-insurance 20% co-insurance 20% co-insurance Not Covered 20% co-insurance 20% co-insurance No charge Not Covered Not Covered Not Covered
Services You May Need Prenatal and postnatal care Delivery and all inpatient services Home health care Rehabilitation services Habilitation services Skilled nursing care Durable medical equipment Hospice services Eye Exam Glasses Dental check-up Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-
Common Medical Event If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care
17
Out-of-Network Provider 40% co-insurance 40% co-insurance 40% co-insurance 40% co-insurance Not Covered 40% co-insurance 40% co-insurance 40% co-insurance Not Covered Not Covered Not Covered
Your Cost if you use an
In-Network Provider 20% co-insurance 20% co-insurance 20% co-insurance 20% co-insurance Not Covered 20% co-insurance 20% co-insurance No charge Not Covered Not Covered Not Covered
Services You May Need Prenatal and postnatal care Delivery and all inpatient services Home health care Rehabilitation services Habilitation services Skilled nursing care Durable medical equipment Hospice services Eye Exam Glasses Dental check-up Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-
Common Medical Event If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care
17
