2 Type of Service Plan Pays In - Network Plan Pays Out - of - Network HOSPITAL FACILITY Inpatient 100% after $500 copay /admit Not covered Outpatient (except emergency room) 100% after $200 copay /visit Not covered Emergency Room 100% after $200 copay /visit 100% after $200 copay (not covered if not a true emergency) Urgent Care Facility 100% after $50 copay /visit Not covered OTHER MEDICAL SERVICES Allergy Testing and Treatment ( physician’s office) 100% after applicable office visit copay Not covered Ambulance Transport 100% after $100 copay /event Not covered Ambulatory Surgical Facility 100% after $50 copay /visit Not covered Bariatric Surgery At Cigna Centers of Excellence if clinical criteria met 100% after $500 facility copay Not covered Chemotherapy 100% after $200 copay / treatment Not covered Chiropractic Care Limit: Maximum of 20 days per calendar year 100% after $50 copay /visit Not covered Diagnostic Lab (Independent Facility) 100% after $20 copay /visit Not covered Diagnostic Lab (Physician’s Office) 100% after applicable office visit copay Not covered Diagnostic X - ray (Independent Facility) 100% after $50 copay /visit Not covered Diagnostic X - ray (Physician’s Office) 100% after applicable office visit copay Not covered Durable Medical Equipment Rental coverage limited to purchase price 100% after $50 copay / item Not covered Home Health Care 100% after $100 copay / visit Not covered