What You Will Pay
Common Medical Event
Limitations, Exceptions, & Other Important Information 50% penalty for no out-of-network precertification. Coverage is limited to 90 days annual max. 50% penalty for no out-of-network precertification. 50% penalty for failure to precertify out-of-network inpatient hospice services.
Services You May Need
In-Network Provider (You will pay the least)
Out-of-Network Provider (You will pay the most)
Skilled nursing care
20% coinsurance
50% coinsurance
Durable medical equipment 20% coinsurance
50% coinsurance
20% coinsurance/inpatient services 20% coinsurance/outpatient services
50% coinsurance/inpatient services 50% coinsurance/outpatient services
Hospice services
Children's eye exam Children's glasses
Not covered Not covered
Not covered Not covered Not covered
None None None
If your child needs dental or eye care
Children's dental check-up Not covered
Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Acupuncture
Eye care (Children) Long-term care Non-emergency care when traveling outside the U.S. Prescription drugs
Private-duty nursing Routine eye care (Adult) Routine foot care Weight loss programs
Cosmetic surgery Dental care (Adult) Dental care (Children)
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Bariatric Surgery (in-network only Surgeon Charges Lifetime max $20,000) Chiropractic care (20 days) Hearing aids ($1,000 maximum per Lifetime) Infertility treatment Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Cigna at 1-800-Cigna24, Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Other coverage options may be available to you, too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.
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