BENEFIT HIGHLIGHTS
IN-NETWORK
OUT-OF-NETWORK
Advanced Cellular Therapy Includes prior authorized advanced cellular therapy products and related services when Medically Necessary. Advanced Cellular Therapy Product
80% after plan deductible 80% after plan deductible 80% after plan deductible 80% after plan deductible
In-Network coverage only In-Network coverage only In-Network coverage only In-Network coverage only In-Network coverage only
Inpatient Facility Outpatient Facility Physician’s Services
Advanced Cellular Therapy Travel Maximum: $10,000 per episode of advanced cellular therapy (Available only for travel when prior authorized to receive advanced cellular therapy from a provider located more than 60 miles of your primary residence and is contracted with Cigna for the specific advanced cellular therapy product and related services.)
No charge
Maternity Care Services Initial Visit to Confirm Pregnancy
No charge after the $30 PCP or $40 Specialist per office visit copay
50% of the Maximum Reimbursable Charge after plan deductible
Note: OB/GYN providers will be considered either as a PCP or Specialist, depending on how the provider contracts with the Insurance Company. All subsequent Prenatal Visits, Postnatal Visits and Physician’s Delivery Charges (i.e. global maternity fee) Physician’s Office Visits in addition to the global maternity fee when performed by an OB/GYN or Specialist Delivery - Facility (Inpatient Hospital, Birthing Center)
80% after plan deductible
50% of the Maximum Reimbursable Charge after plan deductible
No charge after the $30 PCP or $40 Specialist per office visit copay
50% of the Maximum Reimbursable Charge after plan deductible
80% after plan deductible
50% of the Maximum Reimbursable Charge after plan deductible
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