Page 6 - Benefits Summary 2018-2019 b_Neat

Benefits In-Network
Medical Specialty Drugs Home
 This benefit applies to the cost of targeted You pay 30%
Infusion Therapy drugs administered in the Plan pays 70%
patient’s home. This benefit does not cover the
related Professional charges.
PPACA Women’s Health
 Includes surgical services, such as tubal Plan pays 100%,
ligation (excludes reversals) no copay,no deductible
 Contraceptive devices are included.
Family planning
 Includes surgical services, such as vasectomy Varies based on place of service
(excludes reversals)
 Includes infertility testing for diagnosis only
Infertility Not Covered
Abortion
 Includes non-elective procedures and elective Varies based on place of service
procedures
TMJ Varies based on place of service
Organ transplant
 Services paid at network level if performed at
Cigna LifeSOURCE Transplant Network®
Facilities
 Travel maximum $10,000 per transplant (only You pay $350 per admission deductible,
Then
available if using Cigna LifeSOURCE You pay 30%
Transplant Network® facility)
 $350 in-network per admission deductible is Plan pays 70%
separate and in addition to the plan deductible.
Plan deductible only applies to the Professional
Services.
Out-of-area services
 Coverage for services rendered outside a
network area
 ER and Ambulance paid the same as network For all other services
You pay 40%
services
Plan pays 60%
 Preventive care services covered at 100% for after the network deductible is met
out of area
 In-network deductible and out-of-pocket
maximums apply

Pharmacy In-Network Out-of-Network
Cost Share and Supply

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

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