This is a summary of benefits for your Open Access Plus In Network Copay plan.

CIGNA HealthCare Benefit Summary

Wesleyan University

2007 Open Access Plus In-Network Copay Plan

HMO

BENEFIT HIGHLIGHTS	IN-NETWORK
Lifetime Maximum	Unlimited
Calendar Year Deductible Individual Family Maximum Family Maximum Deductible Calculation	None None Not Applicable
Out-of-Pocket Maximum
Includes Deductible	Not Applicable
Includes Copays Does not apply to	Not Applicable Non-compliance penalties, deductibles, copays or charges for mental health, alcohol and drug abuse benefits.
Individual	Not Applicable
Family Maximum	Not Applicable
Automated Annual Reinstatement	Not Applicable
Physician's Services Primary Care Physician's Office visit	No charge after $10 PCP per office visit copay; No charge after the PCP per visit copay if only x-ray and/or lab services performed and billed.
Specialty Care Physician's Office Visit Office Visits Consultant and Referral Physician's Services Note: All OB-GYN visits will be subject to the PCP copay.	No charge after $20 Specialist per office visit copay; No charge after the Specialist per visit copay if only x-ray and/or lab services performed and billed.
Surgery Performed In the Physician's Office	No charge after the PCP or Specialist per office visit copay
Second Opinion Consultations (services will be provided on a voluntary basis)	No charge after the PCP or Specialist per office visit copay
Allergy Treatment/Injections	No charge after either the PCP or Specialist per office visit copay or the actual charge, whichever is less.
Allergy Serum (dispensed by the physician in the office)	No charge
Preventive Care Routine Preventive Care: Well-Baby, Well-Child, Adult and Well-Woman (including immunizations) Note: Well-Woman OB/GYN visits will be subject to the plan’s PCP copay.	No charge after PCP or Specialist per office visit copay; No charge after the PCP or Specialist per visit copay if only x-ray and/or lab services performed and billed. Note: x-ray and/or lab services performed and billed by an independent diagnostic facility or outpatient hospital are covered under the plan’s x-ray/lab benefit.
Immunizations	No charge
Mammograms, PSA, Pap Smear Note: Preventive care related services and diagnostic related services are paid at the same level of benefits as other x-ray and lab services, based on place of service.	No charge
Inpatient Hospital - Facility Services	No charge
Semi Private Room and Board	Limited to semi-private room negotiated rate
Private Room	Limited to semi-private room negotiated rate
Special Care Units (ICU/CCU)	Limited to negotiated rate
BENEFIT HIGHLIGHTS	IN-NETWORK
Outpatient Facility Services Operating Room, Recovery Room, Procedure Room, Treatment Room and Observation Room Note: Non-surgical treatment procedures are not subject to the facility copay.	No charge
Inpatient Hospital Physician’s Visits/Consultations	No charge
Inpatient Hospital Professional Services Surgeon Radiologist Pathologist Anesthesiologist	No charge
Multiple Surgical Reduction	Multiple surgeries performed during one operating session result in payment reduction of 50% of charges to the surgery of lesser charge. The most expensive procedure is paid as any other surgery.
Outpatient Professional Services Surgeon Radiologist Pathologist Anesthesiologist	No charge
Emergency and Urgent Care Services Physician’s Office	No charge after PCP or Specialist per visit copay
Hospital Emergency Room	No charge after $50 per visit copay*
Outpatient Professional services (radiology, pathology and ER Physician)	No charge
Urgent Care Facility or Outpatient Facility	No charge after $25 per visit copay*
Ambulance	No charge**
	*waived if admitted **If not a true emergency, services are not covered
Inpatient Services at Other Health Care Facilities Includes Skilled Nursing Facility, Rehabilitation Hospital and Sub-Acute Facilities 90 days combined maximum per calendar year No prior hospitalization required	No charge
Laboratory and Radiology Services (includes pre-admission testing) Advanced Radiological Imaging (i.e. MRI’s, CAT Scans and PET Scans) Note: The copay applies on a per procedure basis, for any place of service.	No charge
Other Laboratory and Radiology Services Physician’s Office	No charge
Outpatient Hospital Facility	No charge
Emergency Room/Urgent Care Facility (billed by the facility as part of the ER/UC visit)	No charge (if ER/UC facility is covered at no charge after per visit copay)
BENEFIT HIGHLIGHTS	IN-NETWORK
Independent X-ray and/or Lab facility	No charge
Independent X-ray and/or Lab Facility in conjunction with an ER visit	No charge (if ER facility is covered at no charge after per visit copay)
Outpatient Short-Term Rehabilitative Therapy and Chiropractic Services 60 days combined maximum per calendar year Includes: Cardiac Rehab Physical Therapy Speech Therapy Occupational Therapy Chiropractic Therapy (includes Chiropractors) Pulmonary Rehab Cognitive Therapy	No charge after PCP or Specialist per office visit copay; No charge after the PCP or Specialist per visit copay if only x-ray and/or lab services are performed and billed. Note: Outpatient Short Term Rehab copay applies, regardless of place of service, including the home. Note: Therapy days, provided as part of an approved Home Health Care plan, accumulate to the Outpatient Short Term Rehab Therapy maximum. If multiple outpatient services are provided on the same day, they constitute one day, but separate copay will apply to the services provided by each Participating provider.
Home Health Care Unlimited day maximum per calendar year (includes outpatient private duty nursing when approved as medically necessary)