2 Type of Service Plan Pays In - Network Plan Pays Out - of - Network Emergency Room Physician Visit 100% after $100 facility copay 100% after $100 copay (50% after deductible if not a true emergency) HOSPITAL FACILITY Inpatient 100% after $350 copay /admit 50% after deductible Outpatient (except emergency room) 100% after $200 copay /visit 50% after deductible Emergency Room 100% after $100 copay /visit 100% after $100 copay (50% after deductible if not a true emergency) Urgent Care Facility 100% after $50 copay /visit 50% after deductible OTHER MEDICAL SERVICES Allergy Testing and Treatment (physician’s office) 100% after applicable office visit copay 50% after deductible Ambulance Transport 100% after $50 copay /event 50% after deductible Ambulatory Surgical Facility 100% after $50 copay /visit 50% after deductible Bariatric Surgery At Cigna Centers of Excellence if clinical criteria met 100% after $350 facility copay Not covered Chemotherapy 100% after $200 copay /treatment 50% after deductible Chiropractic Care Limit: Maximum of 20 days / calendar year 100% after $40 copay /visit 50% after deductible Diagnostic Lab (Independent Facility) 100% after $10 copay /visit 50% after deductible Diagnostic Lab (Physician’s Office) 100% after applicable office visit copay 50% after deductible Diagnostic X - ray (Ind ependent Facility) 100% after $50 copay /visit 50% after deductible Diagnostic X - ray (Physician’s Office) 100% after applicable office visit copay 50% after deductible Durable Medical Equipment Rental coverage limited to purchase price 100% after $50 copay / item 50% after deductible