Cigna PPO Out-Of-Network

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	BenefitTabs™ for Health and Welfare - Cigna PPO Out-Of-Network


Annual Deductibles
Individual	$500
Family	$1,500
Annual Out of Pocket Maximums
Individual	$3,500
Family	$10,500
Pre-Existing Condition Limitation	$1,000 limit first year
Benefit Maximums
Lifetime	$1,000,000/person (In-and-Out-of-Network combined)
Chiropractic/Year	$300/person
Skilled Nursing Facility/Year	60 consecutive days
Wellness/Year	Not covered
Rehabilitation Therapy [Physical, Speech or Occupational]/Year	60 consecutive days/incident
Outpatient Services (other than Family Planning and Mental Health/Substance Abuse Treatment)
Office Visits	You pay 50%
Physical Exams [Wellness]	Not Covered
Well Child Care and Immunization (Wellness	Not Covered
Surgical Facility	You pay 50%
Lab and X-ray	You pay 50%
Inpatient Services
Hospitilization	You pay 50%
Surgeon's Fees	You pay 50%
Lab and X-ray	You pay 50%
Emergency Room Care [waived if admitted]	You pay 30%
Durable Medical Equipment	You pay 50%
Skilled Nursing Facility	You pay 50%
Family Planning
Prenatal Office Visits	You pay 50%
Delivery	You pay 50%
Vasectomy/Tubal Ligation	You pay 50%
Infertility Office Visits	You pay 50%
Prescription Drugs
Mental Health and Substance Abuse Treatment Annual Deductibles
Individual	Not covered
Family	Not covered
Annual Out-Of-Pocket Maximum	Not covered
Benefit Maximums, Mental Health
Lifetime	Not covered
Inpatient Treatment	Not covered
Benefit Maximums, Substance Abuse
Annual	Not covered
Lifetime	Not covered
Inpatient Treatment	Not covered
Mental Health Treatment
Inpatient Treatment	Not covered
Outpatient Treatment (up to 30 visits/year)	Not covered
Substance Abuse Treatment
Inpatient Treatment	Not covered
Outpatient Treatment	Not covered


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