BENEFIT HIGHLIGHTS
IN-NETWORK
OUT-OF-NETWORK
Dental Care Limited to charges made for a continuous course of dental treatment for an Injury to teeth. Physician’s Office Visit
80% after plan deductible
50% of the Maximum Reimbursable Charge after plan deductible 50% of the Maximum Reimbursable Charge after plan deductible 50% of the Maximum Reimbursable Charge after plan deductible 50% of the Maximum Reimbursable Charge after plan deductible
Inpatient Facility
80% after plan deductible
Outpatient Facility
80% after plan deductible
Physician’s Services
80% after plan deductible
Obesity/Bariatric Surgery Note: Coverage is provided subject to medical necessity and clinical guidelines subject to any limitations shown in the “Exclusions, Expenses Not Covered and General Limitations” section of this certificate. Physician’s Office Visit
80% after plan deductible 80% after plan deductible 80% after plan deductible
In-Network coverage only In-Network coverage only In-Network coverage only
Inpatient Facility Outpatient Facility
Physician’s Services
80% after plan deductible
In-Network coverage only
Surgical Professional Services Lifetime Maximum: $20,000 Notes: • Includes charges for surgeon only; does not include radiologist, anesthesiologist, etc. • Accumulates to the Out-of-Pocket Maximum. • Only surgical services accumulate to the maximum.
myCigna.com
32
Made with FlippingBook Annual report