Page 5 - Benefits Summary 2018-2019 b_Neat

Benefits In-Network
Outpatient mental health – Physician’s Office
 Includes Individual, Intensive Outpatient, You pay $50 per visit copay, then plan pays 100%
Behavioral Telehealth Consultation, and Group
Therapy
Outpatient mental health – all other services
 Includes Partial Hospitalization Plan pays 100%,
 Includes Individual, Intensive Outpatient, no copay,no deductible
Behavioral Telehealth Consultation, and Group
Therapy
Inpatient substance use disorder You pay $350 per admission deductible,
 Includes Residential Treatment then you pay 30%, Plan pays 70%
Outpatient substance use disorder – Physician’s
Office
 Includes Individual, Intensive Outpatient, You pay $50 per visit copay, then plan pays 100%
Behavioral Telehealth Consultation, and Group
Therapy
Outpatient substance use disorder – all other
services
 Includes Partial Hospitalization Plan pays 100%,
 Includes Individual, Intensive Outpatient, no copay,no deductible
Behavioral Telehealth Consultation, and Group
Therapy
Therapy Services
Outpatient physical therapy
 20 visits per plan year Covered same as plan's Physician Office Visit – Specialist
 Limits are not applicable to mental health
conditions
Outpatient speech therapy, hearing therapy and
occupational therapy
 20 visits per plan year Covered same as plan's Physician Office Visit – Specialist
 Limits are not applicable to mental health
conditions for speech and occupational
therapies
Chiropractic services Covered same as plan's Physician Office Visit – Specialist
 20 visits per plan year
Acupuncture Not Covered
Additional Services
Medical Specialty Drugs Inpatient Facility
 This benefit applies to the cost of the Infusion After the plan deductible is met,
Therapy drugs administered in an Inpatient You pay 30%
Facility. This benefit does not cover the related Plan pays 70%
Facility or Professional charges.
Medical Specialty Drugs Outpatient Facility
 This benefit applies to the cost of the Infusion After the plan deductible is met,
Therapy drugs administered in an Outpatient You pay 30%
Facility. This benefit does not cover the related Plan pays 70%
Facility or Professional charges.
Medical Specialty Drugs Physician’s Office
 This benefit applies to the cost of targeted You pay 30%
Infusion Therapy drugs administered in the Plan pays 70%
Physician’s Office. This benefit does not cover
the related Office Visit or Professional charges.

11/1/2018
ASO
Open Access Plus - OAPin Low 11-2018 - 7899882. Version# 12

3 of 8 ©Cigna 2018