Cigna Health Savings Account (HSA) Summary Plan Description

BENEFIT HIGHLIGHTS

IN-NETWORK

OUT-OF-NETWORK

Mental Health Inpatient

80% after plan deductible

50% after plan deductible

Includes Acute Inpatient and Residential Treatment

Calendar Year Maximum: Unlimited Outpatient Outpatient - Office Visits

80% after plan deductible

50% after plan deductible

Includes individual, family and group psychotherapy; medication management, Behavioral Telehealth consultation, etc.

Calendar Year Maximum: Unlimited

Outpatient - All Other Services Includes Partial Hospitalization, Intensive Outpatient Services, Behavioral Telehealth consultation, etc.

80% after plan deductible

50% after plan deductible

Calendar Year Maximum: Unlimited

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