BENEFIT HIGHLIGHTS
IN-NETWORK
OUT-OF-NETWORK
Bereavement Counseling Services provided as part of Hospice Care Inpatient
80% after plan deductible
50% of the Maximum Reimbursable Charge after plan deductible 50% of the Maximum Reimbursable Charge after plan deductible Covered under Mental Health benefit
Outpatient
80% after plan deductible
Services provided by Mental Health Professional Condition-Specific Care Includes select Medically Necessary preauthorized services, supplies, and/or surgical procedures, subject to program participation requirements. Charges for covered expenses not preauthorized as included in the program are payable subject to applicable copayments, coinsurance, and deductible if any. If you choose to not actively enroll in the program, do not complete the program participation requirements, or utilize a provider who is not designated for the program, charges for covered expenses are payable subject to applicable copayments, coinsurance, and deductible if any. Condition-Specific Care Travel Maximum $600 per procedure Approved travel amount is variable, up to the travel maximum per procedure, based on factors such as a patient’s treatment plan, location and duration of facility stay; and subject to program participation requirements.
Covered under Mental Health benefit
100%
In-Network coverage only
100%
Not Applicable
myCigna.com
25
Made with FlippingBook - Online magazine maker