BENEFIT HIGHLIGHTS
IN-NETWORK
OUT-OF-NETWORK
Condition-Specific Care Physical Therapy Services Addresses spine, knee, hip, or shoulder pain, up to 5 visits, subject to Outpatient Physical Therapy maximum(s). To qualify, you must enroll in the Cigna Pathwell Bone & JointSM program and complete the program’s Welcome Assessment. Outpatient Cardiac Rehabilitation Calendar Year Maximum: 36 days
No charge
In-Network coverage only
No charge after the $40 Specialist per office visit copay
50% of the Maximum Reimbursable Charge after plan deductible
Chiropractic Care Calendar Year Maximum: 20 days Physician’s Office Visit
No charge after the $30 PCP or $40 Specialist per office visit copay
50% of the Maximum Reimbursable Charge after plan deductible
Home Health Care Services Calendar Year Maximum:
80% after plan deductible
50% of the Maximum Reimbursable Charge after plan deductible
120 days (includes outpatient private nursing when approved as Medically Necessary) Dialysis services in the home setting will not accumulate to the Home Health Care maximum (The limit is not applicable to Mental Health and Substance Use Disorder conditions.) . Hospice Inpatient Services
80% after plan deductible
50% of the Maximum Reimbursable Charge after plan deductible 50% of the Maximum Reimbursable Charge after plan deductible
Outpatient Services (same coinsurance level as Home Health Care Services)
80% after plan deductible
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