Open Access Plus Medical Benefits The Schedule
Accumulation of Plan Deductibles and Out-of-Pocket Maximums Deductibles and Out-of-Pocket Maximums will accumulate in one direction (that is, Out-of-Network will accumulate to In-Network). All other plan maximums and service-specific maximums (dollar and occurrence) cross-accumulate between In- and Out-of-Network unless otherwise noted. . Note: For information about your health fund benefit and how it can help you pay for expenses that may not be covered under this plan, refer to “What You Should Know about Cigna Choice Fund”. Multiple Surgical Reduction Multiple surgeries performed during one operating session result in payment reduction of 50% to the surgery of lesser charge. The most expensive procedure is paid as any other surgery.
Assistant Surgeon and Co-Surgeon Charges
Assistant Surgeon The maximum amount payable will be limited to charges made by an assistant surgeon that do not exceed a percentage of the surgeon's allowable charge as specified in Cigna Reimbursement Policies. (For purposes of this limitation, allowable charge means the amount payable to the surgeon prior to any reductions due to coinsurance or deductible amounts.) Co-Surgeon The maximum amount payable for charges made by co-surgeons will be limited to the amount specified in Cigna Reimbursement Policies. Out-of-Network Emergency Services Charges 1. Emergency Services are covered at the In-Network cost-sharing level if services are received from a non-participating (Out-of-Network) provider. 2. The allowable amount used to determine the Plan’s benefit payment for covered Emergency Services rendered in an Out-of-Network Hospital, or by an Out-of-Network provider in an In-Network Hospital, is the amount agreed to by the Out-of-Network provider and Cigna, or if no amount is agreed to, the greatest of the following, not to exceed the provider’s billed charges: (i) the median amount negotiated with In-Network providers for the Emergency Service, excluding any In-Network copay or coinsurance; (ii) the Maximum Reimbursable Charge; or (iii) the amount payable under the Medicare program. The member is responsible for applicable In-Network cost-sharing amounts (any deductible, copay or coinsurance). The member is also responsible for all charges that may be made in excess of the allowable amount. If the Out-of-Network provider bills you for an amount higher than the amount you owe as indicated on the Explanation of Benefits (EOB), contact Cigna Customer Service at the phone number on your ID card.
BENEFIT HIGHLIGHTS
IN-NETWORK
OUT-OF-NETWORK
Unlimited
Lifetime Maximum
80%
50% of the Maximum Reimbursable Charge
The Percentage of Covered Expenses the Plan Pays
Note: "No charge" means an insured person is not required to pay Coinsurance.
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