• inpatient services at any participating Other Health Care Facility. • residential treatment. • outpatient facility services. • partial hospitalization. • advanced radiological imaging. • non-emergency Ambulance. • certain Medical Pharmaceuticals. • home health care services.
• charges for outpatient medical care and treatment received at a Free-Standing Surgical Facility. • charges for Emergency Services. • charges for Urgent Care. • charges by a Physician or a Psychologist for professional services. • charges by a Nurse for professional nursing service. • charges for anesthetics, including, but not limited to supplies and their administration. • charges for diagnostic x-ray. • charges for advanced radiological imaging, including for example CT Scans, MRI, MRA and PET scans and laboratory examinations, x-ray, radiation therapy and radium and radioactive isotope treatment and other therapeutic radiological procedures. • charges for chemotherapy. • charges for blood transfusions. • charges for oxygen and other gases and their administration. • charges for Medically Necessary foot care for diabetes, peripheral neuropathies, and peripheral vascular disease. • charges for screening prostate-specific antigen (PSA) testing. • charges for laboratory services, radiation therapy and other diagnostic and therapeutic radiological procedures. • charges for abortion when a Physician certifies in writing that the pregnancy would endanger the life of the mother, or when the expenses are incurred to treat medical complications due to abortion. • charges for Men’s family planning, counseling, testing and sterilization (e.g. vasectomies), excluding reversals. • charges for the following preventive care services as defined by recommendations from the following: • the U.S. Preventive Services Task Force (A and B recommendations); • the Advisory Committee on Immunization Practices (ACIP) for immunizations; • the American Academy of Pediatrics’ Periodicity Schedule of the Bright Futures Recommendations for Pediatric Preventive Health Care; • the Uniform Panel of the Secretary’s Advisory Committee on Heritable Disorders in Newborns and Children; and • with respect to women, evidence-informed preventive care and screening guidelines supported by the Health Resources and Services Administration.
• radiation therapy. • transplant services.
HC-PRA55
01-22 V1
Covered Expenses The term Covered Expenses means expenses incurred by a person while covered under this plan for the charges listed below for: • preventive care services; and • services or supplies that are Medically Necessary for the care and treatment of an Injury or a Sickness, as determined by Cigna. As determined by Cigna, Covered Expenses may also include all charges made by an entity that has directly or indirectly contracted with Cigna to arrange, through contracts with providers of services and/or supplies, for the provision of any services and/or supplies listed below. Any applicable Copayments, Deductibles or limits are shown in The Schedule. Covered Expenses • charges for inpatient Room and Board and other Necessary Services and Supplies made by a Hospital, subject to the limits as shown in The Schedule. • charges for inpatient Room and Board and other Necessary Services and Supplies made by an Other Health Care Facility, including a Skilled Nursing Facility, a Rehabilitation Hospital or a subacute facility as shown in The Schedule. • charges for licensed Ambulance service to the nearest Hospital where the needed medical care and treatment can be provided. • charges for outpatient medical care and treatment received at a Hospital.
myCigna.com
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