inpatient services at any participating Other Health Care Facility. residential treatment. outpatient facility services. partial hospitalization.
charges made on its own behalf, by an Other Health Care Facility, including a Skilled Nursing Facility, a Rehabilitation Hospital or a subacute facility for medical care and treatment; except that for any day of Other Health Care Facility confinement, Covered Expenses will not include that portion of charges which are in excess of the Other Health Care Facility Daily Limit shown in The Schedule. charges made for Emergency Services and Urgent Care. charges made by a Physician or a Psychologist for professional services. charges made by a Nurse, other than a member of your family or your Dependent’s family, for professional nursing service. charges made for anesthetics and their administration; diagnostic x-ray and laboratory examinations; x-ray, radium, and radioactive isotope treatment; chemotherapy; blood transfusions; oxygen and other gases and their administration. charges made for an annual prostate-specific antigen test (PSA). charges made for laboratory services, radiation therapy and other diagnostic and therapeutic radiological procedures. charges made for Family Planning, including medical history, physical exam, related laboratory tests, medical supervision in accordance with generally accepted medical practices, other medical services, information and counseling on contraception, implanted/injected contraceptives, after appropriate counseling, medical services connected with surgical therapies (tubal ligations, vasectomies). 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 made for the following preventive care services (detailed information is available at www.healthcare.gov.): (1) evidence-based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force; (2) immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the covered person involved; (3) for infants, children, and adolescents, evidence- informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration;
intensive outpatient programs. advanced radiological imaging. non-emergency ambulance. certain Medical Pharmaceuticals. home health care services.
radiation therapy. transplant services.
HC-PRA41
01-19
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 made by a Hospital, on its own behalf, for Bed and Board and other Necessary Services and Supplies; except that for any day of Hospital Confinement, Covered Expenses will not include that portion of charges for Bed and Board which is more than the Bed and Board Limit shown in The Schedule. charges for licensed ambulance service to or from the nearest Hospital where the needed medical care and treatment can be provided. charges made by a Hospital, on its own behalf, for medical care and treatment received as an outpatient. charges made by a Free-Standing Surgical Facility, on its own behalf for medical care and treatment.
29
myCigna.com
Made with FlippingBook Publishing Software