Covered expenses

The term Covered Expenses means the expenses incurred by or on behalf of a covered person for the charges listed below. Expenses incurred for such charges are considered Covered Expenses to the extent that the services or supplies provided are recommended by a Physician and are essential for the necessary care and treatment of an Injury or Sickness. For expenses incurred for such charges to be considered Covered Expenses, the services or supplies provided must be Medically Necessary.

No Cigna Option benefits are payable unless the services or supplies are Covered Expenses recommended by and received from, or approved by, Participating Providers and are authorized by the Provider Organization, except in the case of Emergency Services. For Emergency Services from non-participating providers, participants must submit a claim no later than 60 days after the first Emergency Service is provided or as soon as reasonably possible. The claim should contain an itemized statement of treatment, expenses, and diagnosis.

Other limitations are shown in the General limitations section.

Preventive care and wellness

This section describes the eligible health services and supplies available under your plan when you are well.

Routine physical exams

Covered services include office visits to your physician, PCP or other health professional for routine physical exams. This includes routine vision (through age 18) and hearing screenings (through age 21) given as part of the exam. A routine exam is a medical exam given by a physician for a reason other than to diagnose or treat a suspected or identified illness or injury.

Preventive care immunizations

Covered health services include immunizations for infectious diseases but does not include coverage of immunizations that are not considered preventive care, such as those for employment or travel.

Well woman preventive visits

Covered health services include routine well woman preventive exam office visit, including pap smears, general pelvic exams, and manual breast exams which are given for a reason other than to diagnose or treat a suspected or identified illness or injury.

Preventive screening and counseling services

Covered health services include screening and counseling by your health professional for some conditions. These include obesity, substance use disorders, use of tobacco products, sexually transmitted infection counseling and genetic risk counseling for breast and ovarian cancer.

Routine cancer screenings

Covered health services include the following routine cancer screenings:

• Mammograms
• Prostate specific antigen (PSA) tests
• Colonoscopies which include removal of polyps performed during a screening procedure, and a pathology exam on any removed polyps
• Lung cancer screenings

Prenatal care

Covered health services include the routine prenatal physical exams to monitor maternal weight, blood pressure, fetal heart rate, and fundal height. Note that some prenatal care is billed at the coinsurance rate (reference the Benefit Summary section for more information).

Breast feeding durable medical equipment

Coverageincludes renting or buying durable medical equipment you need to pump and store breast milk as follows:

• Breast pump:

• Renting a hospital grade electric pump while your newborn child is confined in a hospital.
• The buying of:

• An electric breast pump (non-hospital grade). Your plan will cover this cost once per pregnancy, or
• A manual breast pump. Your plan will cover this cost once per pregnancy.

• Breast pump supplies and accessories

• These are limited to only one purchase per pregnancy in any year where a covered female would not qualify for the purchase of a new pump.
• Coverage for the purchase of breast pump equipment is limited to one item of equipment, for the same or similar purpose, and the accessories and supplies needed to operate the item.
• You are responsible for the entire cost of any pieces of the same or similar equipment you purchase or rent for personal convenience or mobility.

Family planning services – female contraceptives

Covered family planning services include counseling services provided by your provider on contraceptive methods, contraceptive devices, and voluntary sterilization (tubal litigation).

Physicians and other health professionals

Physician services

• 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 Eligible Family Member's family, for professional services.
• Charges made for Telemedicine general medical services and/or behavioral health services provided by Cigna’s designated telemedicine providers as permissible under applicable state and local law. To learn more or initiate services, connect with MDLIVE at myCigna.com or call 1-888-726-3171.

Alternatives to physician office visits (walk-in clinic)

Covered services include health care services provided in contracted convenience care clinics (for unscheduled, non-medical emergency illnesses and injuries and for immunizations, where administration is within the scope of the clinic’s license).

Hospital and other facility care

Hospital care

• 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 In Patient Stay, Covered Expenses will not include that portion of charges for Bed and Board which is more than the Hospital’s negotiated rate for a semi-private room.
• 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.

Alternatives to hospital stays

Outpatient surgery and physician surgical services

• Charges made for varicose veins surgery when medically necessary.
• If multiple outpatient services are provided on the same day they constitute one visit, but a separate coinsurance will apply to the services provided by each provider.

Home health care

• Charges made for Home Health Care Services when you; (a) require skilled care; (b) are unable to obtain the required care as an ambulatory outpatient; and (c) do not require in patient stay in a Hospital or Other Health Care Facility. Home Health Care Services are provided only if Cigna has determined that the home is a medically appropriate setting. If you are a minor or an adult who is dependent upon others for non-skilled care (e.g., bathing, eating, toileting), Home Health Services will only be provided for you during times when there is a family member or care giver present in the home to meet your non-skilled care needs. Home Health Services are those skilled health care services that can be provided during visits by Other Health Care Professionals. The services of a home health aide are covered when rendered in direct support of skilled health care services provided by Other Health Professionals. A visit is defined as a period of 2 hours or less. Home Health Services are subject to a maximum of 16 hours in total per day. Necessary consumable medical supplies and home infusion therapy administered or used by Other Health Professionals in providing Home Health Services are covered. Home Health Services do not include services by a person who is a member of your family or your Eligible Family Member's family or who normally resides in your house or your Eligible Family Member's house even if that person is an Other Health Professional. Physical, occupational, and other Short-Term Rehabilitative Therapy services provided in the home are not subject to the Home Health Services benefit limitations in the Schedule, but are subject to the benefit limitations described under Short-Term Rehabilitative Therapy Maximum shown in the In-Network Benefits Schedule.
• Covered Expenses do not include charges made by a Home Health Care Agency for: (a) care or treatment which is not stated in the Home Health Care Plan; (b) the services of a person who is a member of your family or your Eligible Family Member's family or who normally lives in your home or your Eligible Family Member's home; or (c) a period when a person is not under the continuing care of a Physician.

Hospice care

• Charges made for you or a covered family member who has been diagnosed as having six months or fewer to live, due to Terminal Illness, for the following Hospice Care Services provided under a Hospice Care Program: (a) by a Hospice Facility for Bed and Board and Services and Supplies, except that, for any day of admission in a private room, Covered Expenses will not include that portion of charges which is more than the Hospice Bed and Board Limit shown in the In-Network Benefits Schedule; (b) by a Hospice Facility for services provided on an outpatient basis; (c) by a Physician for professional services; (d) by a Psychologist, social worker, family counselor or ordained minister for individual and family counseling, including bereavement counseling within one year after the person's death; (e) for pain relief treatment, including drugs, medicines and medical supplies; (f) by a Home Health Care Agency for: part-time or intermittent nursing care by or under the supervision of a Nurse; or part-time or intermittent services of a Home Health Aide; (g) physical, occupational and speech therapy; and (h) medical supplies; drugs and medicines lawfully dispensed only on the written prescription of a Physician; and laboratory services; but only to the extent such charges would have been payable under the Cigna Option if the person had remained or been admitted to a Hospital or Hospice Facility.
• The following charges for Hospice Care Services are not included as Covered Expenses:

• For the services of a person who is a member of your family or your Eligible Family Member's family or who normally resides in your house or your Eligible Family Member's house;
• For any period when you or your Eligible Family Member is not under the care of a Physician;
• For services or supplies not listed in the Hospice Care Program;
• For any curative or life-prolonging procedures;
• To the extent that any other benefits are payable for those expenses under the Cigna Option;
• For services or supplies that are primarily to aid you or your Eligible Family Member in daily living;
• For more than three bereavement counseling sessions;
• For services for respite care; or
• For nutritional supplements, non-prescription drugs or substances, medical supplies, vitamins or minerals, except as required by applicable law.

Skilled nursing facility

• Charges made by a Skilled Nursing Facility, on its own behalf, for medical care and treatment; except that for any day of Skilled Nursing Facility stay, Covered Expenses will not include that portion which is more than the Skilled Nursing Facility Limit shown in the In-Network Benefits Schedule; nor will benefits be payable for more than the maximum number of days shown in the In-Network Benefits Schedule. Benefits for Rehabilitative Hospitals and Sub-Acute Facilities are also included.

Emergency services and urgent care

• Charges made for Emergency Services and Urgent Care

Specific conditions

Maternity and related newborn care

Covered services include prenatal and postpartum care and obstetrical services. After your child is born, eligible health services include:

• 3 days of inpatient care in a hospital or birthing center after a vaginal delivery
• 5 days of inpatient care in a hospital or birthing center after a cesarean delivery
• A shorter stay, if the attending physician, with the consent of the mother, discharges the mother or newborn earlier

A birthing center is a facility specifically licensed as a freestanding birthing center by applicable state and federal laws to provide prenatal care, delivery and immediate postpartum care.

Coverage also includes the services and supplies needed for circumcision by a provider.

Mental health treatment

• Charges made for Mental Health Services:

• Charges made by a facility licensed to furnish mental health services, on its own behalf, for care and treatment of mental health condition provided on an inpatient or outpatient basis.
• Mental health services are services that are required to treat a disorder that impairs the behavior, emotional reaction or thought processes. In determining benefits payable, charges made for the treatment of any physiological conditions related to Mental Health will not be considered to be charges made for treatment of Mental Health.
• Inpatient mental health services are services provided by a facility designated for the treatment and evaluation of Mental health condition. In lieu of hospitalization and upon authorization by Cigna, coverage can be provided in a participating Psychiatric Day Treatment Center, Crisis Stabilization Unit, or Residential Treatment Center for Children and Adolescents.
• Outpatient mental health services are services of participating providers qualified to treat Mental health condition on an outpatient basis for treatment of conditions such as: anxiety or depression interfering with daily functioning; emotional adjustment or concerns related to chronic conditions, such as psychosis or depression; emotional reactions associated with marital problems or divorce; child/adolescent problems of conduct or poor impulse control; affective disorders; suicidal or homicidal threats or acts; eating disorders; acute exacerbation of chronic mental health condition (crisis intervention and relapse prevention). Coverage will also be provided for outpatient testing and assessment as authorized.
• Adjunctive group therapy can be utilized for treatment of depression, stress, phobia or other emotional disorders as authorized.

Substance use disorder treatment

• Charges made by a facility licensed to furnish treatment of alcohol and drug abuse, on its own behalf, for care and treatment provided on an inpatient or outpatient basis.
• Substance use disorder is defined as the psychological or physical dependence on alcohol or other mind-altering drugs requiring diagnosis, care, and treatment. To determine benefits payable, charges made for the treatment of any physiological conditions related to rehabilitation services for alcohol or drug abuse or addiction will not be considered to be charges made for treatment of substance use disorder.

Prior Mental Health/Substance Use Disorder Treatment

Examples of expenses or services that are not Allowable Expenses include, but are not limited to the following:

• An expense or service or a portion of an expense or service that is not covered by any of the plans is not an Allowable Expense.
• If you are confined to a private Hospital room and no Group Health Plan provides coverage for more than a semiprivate room, the difference in cost between a private and semiprivate room is not an Allowable Expense.
• If you are covered by two or more Group Health Plans that provide services or supplies on the basis of reasonable and customary fees, any amount in excess of the highest reasonable and customary fee is not an Allowable Expense.
• If you are covered by one Group Health Plan that provides services or supplies on the basis of reasonable and customary fees and one Group Health Plan that provides services and supplies on the basis of negotiated fees, the Primary Group Health Plan’s fee arrangement shall be the Allowable Expense.
• If your benefits are reduced under the Primary Group Health Plan (through the imposition of a higher copayment amount, higher coinsurance percentage, a deductible and/or a penalty) because you did not comply with Group Health Plan provisions or because you did not use a preferred provider, the amount of the reduction is not an Allowable Expense. Such Group Health Plan provisions include second surgical opinions and precertification of admissions or services.

Reconstructive surgery and supplies

• Charges made for cosmetic procedures, when medically necessary as defined by Cigna’s clinical guidelines
• Charges made for reconstructive surgery following a mastectomy; benefits include:  (a) surgical services for reconstruction of the breast on which surgery was performed; (b) surgical services for reconstruction of the non-diseased breast to produce symmetrical appearance; (c) postoperative breast prostheses; and (d) mastectomy bras and external prosthetics, limited to the lowest cost alternative available that meets external prosthetic placement needs. During all stages of mastectomy, treatment of physical complications, including lymphedema therapy are covered.
• Charges made for reconstructive surgery or therapy to repair or correct a severe facial disfigurement or severe physical deformity (other than abnormalities of the jaw related to TMJ disorder) provided that (a) the surgery or therapy restores or improves function; or (b) reconstruction is required as a result of medically necessary non-cosmetic surgery; or (c) the surgery or therapy is performed prior to age 19 and is required as a result of the congenital absence or agenesis (lack of formation or development) of a body part including, but not limited to:  microtia, amastia, and Poland Syndrome. Repeat or subsequent surgeries for the same condition are covered only when there is the probability of significant additional improvement as determined by Cigna.

Gene Therapy Benefits

• For certain gene therapy medications, the Embarc Gene Therapy Protection program allows members to receive life-changing medications with no out of pocket drug costs. As of 1/1/23, included medications are Luxturna®, Zolgensma®, Zynteglo®, and Skysona®, and Hemgenix, Cigna will be performing the prior authorization requests and your clinician can request a review as needed by contacting Cigna at 1-800-818-9440.

Cost share for associated medical claims, i.e. related inpatient stays, would still apply. Due to the rare nature of these medications and limited network access, medical claims associated with the administration of an a covered gene therapy medication within this program will be considered non-volitional, which means they will be covered and adjudicated at the in-network level. Questions about medical claims should still be directed to Cigna.

Transplant services

• Charges made for human organ and tissue transplant services at designated facilities through the United States. All Organ Transplant Services listed below, other than cornea, kidney and autologous bone marrow/stem cell transplants are available when received at a qualified or provisional Cigna Lifesource Organ Transplant Network facility. The transplants that are covered at Participating Provider facilities, other than a Cigna Lifesource Organ Transplant Network facility are cornea, kidney and autologous bone marrow/stem cell transplants.
• Coverage is subject to the following conditions and limitations:
• Charges made for human organ and tissue Transplant services which include solid organ and bone marrow/stem cell procedures at designated facilities throughout the United States or its territories. This coverage is subject to the following conditions and limitations.
• Transplant services include the recipient’s medical, surgical and Hospital services; inpatient immunosuppressive medications; and costs for organ or bone marrow/stem cell procurement. Transplant services are covered only if they are required to perform any of the following human to human organ or tissue transplants: allogeneic bone marrow/stem cell, autologous bone marrow/stem cell, cornea, heart, heart/lung, kidney, kidney/pancreas, liver, lung, pancreas or intestine which includes small bowel-liver or multi-visceral.
• All Transplant services, other than cornea, are covered at 90% when received at Cigna LIFESOURCE Transplant Network® facilities. Cornea transplants are not covered at Cigna LIFESOURCE Transplant Network® facilities. Transplant services, including cornea, received at participating facilities specifically contracted with Cigna for those Transplant services, other than Cigna LIFESOURCE Transplant Network® facilities, are payable at the In-Network level. Transplant services received at any other facilities, including Non-Participating Providers and Participating Providers not specifically contracted with Cigna for Transplant services, are not covered.
• Coverage for organ procurement costs are limited to costs directly related to the procurement of an organ, from a cadaver or a live donor. Organ procurement costs shall consist of surgery necessary for organ removal, organ transportation and the transportation (refer to Transplant Travel Services), hospitalization and surgery of a live donor. Compatibility testing undertaken prior to procurement is covered if Medically Necessary. Costs related to the search for, and identification of a bone marrow or stem cell donor for an allogeneic transplant are also covered.
• Charges made for nontaxable travel expenses incurred by you in connection with a preapproved organ/tissue transplant are covered subject to the following conditions and limitations. Transplant travel benefits are not available for cornea transplants. Benefits for transportation and lodging are available to you only if you are the recipient of a preapproved organ/tissue transplant from a designated Cigna LIFESOURCE Transplant Network® facility. The term recipient is defined to include a person receiving authorized transplant related services during any of the following: evaluation, candidacy, transplant event, or posttransplant care. Travel expenses for the person receiving the transplant will include charges for: transportation to and from the transplant site (including charges for a rental car used during a period of care at the transplant facility); and lodging while at, or traveling to and from the transplant site.
• In addition to your coverage for the charges associated with the items above, such charges will also be considered covered travel expenses for one companion to accompany you. The term companion includes your spouse, a member of your family, your legal guardian, or any person not related to you, but actively involved as your caregiver who is at least 18 years of age. The following are specifically excluded travel expenses: any expenses that if reimbursed would be taxable income, travel costs incurred due to travel within 60 miles of your home; food and meals; laundry bills; telephone bills; alcohol or tobacco products; and charges for transportation that exceed coach class rates.
• These benefits are only available when the covered person is the recipient of an organ/tissue transplant. Travel expenses for the designated live donor for a covered recipient are covered subject to the same conditions and limitations noted above. Charges for the expenses of a donor companion are not covered. No benefits are available when the covered person is a donor.

These benefits are only available when the covered person is the recipient of an organ/tissue transplant. Travel expenses for the designated live donor for a covered recipient are covered subject to the same conditions and limitations noted above.  Charges for the expenses of a donor companion are not covered.  No benefits are available when the covered person is a donor

Imaging, Lab Work, and Other Services

Diagnostic complex imaging services

Charges made for complex imaging services by a provider, including:

• Inpatient substance use disorder rehabilitation services are services provided In-Network for rehabilitation, while you or your eligible Family Member are admitted to a Hospital, requiring diagnosis and treatment of abuse or addiction to alcohol and/or drugs. Inpatient Substance Use Disorder Services include Partial Hospitalization sessions.

• Outpatient substance use disorder rehabilitation services are services provided for the diagnosis and treatment of abuse or addiction to alcohol and/or drugs, while you or your eligible Family Member is not admitted to a Hospital, including outpatient rehabilitation in an individual, group, structured group or in a Substance Use Disorder Intensive Outpatient Structured Therapy Program.  A Substance Use Disorder Outpatient Structured Therapy Program consists of distinct levels or phases of treatment that are provided by a certified/licensed substance use disorder program. Intensive Outpatient Structured Therapy programs provide a combination of individual, family and/or group therapy.

• Substance use disorder detoxification services are detoxification and related medical ancillary services provided when required for the diagnosis and treatment of addiction to alcohol and/or drugs. Cigna will decide, based on the Medical Necessity of each situation, whether such services will be provided in an inpatient or outpatient setting.

Complex imaging for preoperative testing is covered under this benefit.

Diagnostic lab work and radiological services

• 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; formulas for infants (less than one year of age) with PKU, Maple Disease, Histidinemia or Homocystinuria.

Short-term rehabilitation services

• Charges made for Short-Term Rehabilitative Therapy that is part of a rehabilitation program which is medically necessary, including physical, speech, occupational, cognitive, cardiac rehabilitation and pulmonary rehabilitation therapy, when provided in the most medically appropriate setting. Services are provided on an outpatient basis are limited to sixty (60) days per Contract Year for any combination of these therapies, but only if significant improvement can be expected. The maximum day limit for Rehabilitative Therapy does not apply to occupational therapy, physical therapy or speech therapy prescribed for the treatment of covered mental health conditions, including Autism Spectrum Disorder, Down syndrome, cerebral palsy, fetal alcohol syndrome, muscular dystrophy, and other covered developmental delays.
• The following benefit limitations apply to Short-Term Rehabilitative Therapy and Chiropractic Care services:

• Services which are considered custodial or educational in nature are not covered.
• Occupational therapy provided only for purposes of enabling performance of the activities of daily living is not covered.

Other services

• Nutritional Evaluation and counseling from a Participating Provider is offered when diet is part of the medical management of a documented disease, including morbid obesity.  

Ambulance service

Charges are covered for licensed ambulance service to or from the nearest Hospital where the needed medical care and treatment can be provided.

Durable medical equipment (DME)

• Charges made for the purchase or rental of Durable Medical Equipment that is ordered or prescribed by a Physician and provided by a vendor approved by Cigna for use outside a Hospital or Other Health Care facility. Coverage for repair, replacement or duplicate equipment is provided only when required due to anatomical change and/or reasonable wear and tear. All maintenance and repairs that result from misuse are your responsibility. Durable Medical Equipment is defined as items which are designed for and able to withstand repeated use by more than one person; customarily serve a medical purpose; generally are not useful in the absence of Injury or Sickness; are appropriate for use in the home; and are not disposable. Such equipment includes, but is not limited to, crutches, hospital beds, wheel chairs, and dialysis machines. Charges made for or in connection with approved organ transplant services, including immunosuppressive medication; organ procurement costs; and donor's medical costs. The amount payable for donor's medical costs will be reduced by the amount payable for those costs from any other plan. Certain transplants will not be covered based on General Limitations. Contact Cigna before you incur any such costs.

Prosthetic devices

• Charges for the purchase, maintenance or repair of internal prosthetic medical appliances consisting of permanent or temporary internal aids and supports for defective body parts; specifically intraocular lenses, artificial heart valves, cardiac pacemakers, artificial joints, intrauterine devices and other surgical materials such as screw nails sutures, and wire mesh; excluding all other prostheses.
• Charges for external breast prostheses incidental to a mastectomy (the Copayments and Maximums for external prostheses do not apply to breast prostheses).
• Charges made for the initial purchase and fitting of external prosthetic devices ordered or prescribed by a Physician which are to be used as replacements or substitutes for missing body parts and are necessary for the alleviation or correction of Sickness, Injury or congenital defect. External prosthetic devices shall include:

• Basic limb prosthetics; terminal devices such as hands or hooks; braces and splints; non-foot orthoses. Only the following non-foot orthoses are covered: (a) rigid and semirigid custom fabricated orthoses, (b) semirigid prefabricated and flexible orthoses; and (c) rigid prefabricated orthoses including preparation, fitting and basic additions, such as bars and joints.

• Custom foot orthotic. Custom foot orthotics are only covered as follows:

• For covered persons with impaired peripheral sensation and/or altered peripheral circulation (e.g. diabetic neuropathy and peripheral vascular disease).
• When the foot orthotic is an integral part of a leg brace and it is necessary for the proper functioning of the brace.
• When the foot orthotic is for use as a replacement or substitute for a missing part of the foot (e.g. amputation) and is necessary for the alleviation or correction of illness, injury, or congenital defect.
• For covered persons with neurologic or neuromuscular condition (e.g. cerebral palsy, hemiplegia, spina bifida) producing spasticity, malalignment, or pathological positioning of the foot and there is reasonable expectation of improvement.

• The following are specifically excluded:

• External power enhancements or power controls for prosthetic limbs and terminal devices;
• Orthotic shoes, shoe additions, procedures for foot orthopedic shoes, shoe modifications and transfers; and
• Orthoses primarily used for cosmetic rather than functional reasons.
• Replacement and repair of external prosthetic appliances is covered only when required due to reasonable wear and tear and/or anatomical change. All maintenance and repairs that result from the covered person's misuse are the covered person's responsibility.

Spinal manipulation

Charges made for services that are provided by a Participating chiropractic Physician when provided in an outpatient setting. Services of a chiropractic Physician include the management of neuro musculoskeletal conditions through manipulation and ancillary physiological treatment that is rendered to restore motion, reduce pain and improve function. Such coverage is available only for rehabilitation following injuries, surgery or medical conditions.