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

CIGNA HealthCare Benefit Summary

Wesleyan University

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) Note: The maximum number of hours per day is limited to 16 hours. Multiple visits can occur in one day; with a visit defined as a period of 2 hours or less (e.g. maximum of 8 visits per day).	No charge
Hospice Inpatient Services Outpatient Services	No charge No charge
Bereavement Counseling
Services provided as part of Hospice Care Inpatient (same coinsurance level as Inpatient Hospice Facility) Outpatient (same coinsurance level as Outpatient Hospice)	No charge No charge
Services provided by Mental Health Professional	Covered under Mental Health benefit
Maternity Care Services Initial Visit to Confirm Pregnancy Note: All OB-GYN visits will be subject to the 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 are performed and billed.
All Subsequent Prenatal Visits, Postnatal Visits, and Physician’s Delivery Charges (i.e. global maternity fee)	No charge
Office Visits in addition to the global maternity fee when performed by an OB or Specialist	No charge after the 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.
Delivery – Facility (Inpatient Hospital, Birthing Center)	No charge
Abortion Includes elective and non‑elective procedures
Inpatient Facility	No charge
Outpatient Surgical Facility	No charge
Physician’s Office	No charge after the 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.
Outpatient Professional Services	No charge
Inpatient Professional Services	No charge
Family Planning Services Office Visits, Lab and Radiology Tests and Counseling Note: The standard benefit will include coverage for contraceptive devices (e.g. Depo-Provera, Norplant and Intrauterine Devices (IUDs). Diaphragms will also be covered when services are provided in the physician's office.	No charge after the 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: Charges billed by an independent x-ray/lab facility or outpatient hospital will be covered under the plan’s x-ray/lab benefit.
Surgical Sterilization Procedure for Vasectomy/Tubal Ligation (excludes reversals) Inpatient Facility	No charge
Outpatient Facility	No charge
Inpatient Physician's Services	No charge
Outpatient Physician's Services	No charge
Physician’s Office	No charge after the 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.
Infertility Treatment Coverage will be provided for the following services: · Testing and treatment services performed in connection with an underlying medical condition. · Testing performed specifically to determine the cause of infertility. · Treatment and/or procedures performed specifically to restore fertility (e.g. procedures to correct an infertility condition). · Artificial Insemination, In-vitro, GIFT, ZIFT, etc. Office Visit (tests, counseling) Inpatient Facility Outpatient Facility Physician Services $15,000 lifetime maximum per member includes all related services billed with an infertility diagnosis (i.e. x-ray or lab services billed by an independent facility)	No charge after the PCP or Specialist per office visit copay; no charge for x-ray/lab if billed by a separate outpatient diagnostic facility such as a hospital No charge No charge No charge
Organ Transplant Includes all medically appropriate, non‑experimental transplants Office Visit	No charge after the PCP or Specialist per office visit copay
Inpatient Facility	No charge
Physician’s Services	No charge
Travel Services Maximum- only available for Lifesource facilities	$10,000 per transplant/per Lifetime maximum
Durable Medical Equipment $3,500 maximum per calendar year	No charge
External Prosthetic Appliances $1,500 maximum per calendar year	No charge
Dental Care Limited to charges made for a continuous course of dental treatment started within six months of an injury to sound, natural teeth.
Doctor’s Office	No charge after the 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.
Inpatient Facility	No charge
Outpatient Surgical Facility	No charge
Physician’s Services	No charge
TMJ - Non-surgical Provided on a limited, case by case basis. Always exclude appliances and orthodontic treatment. Subject to medical necessity. Doctor’s Office Inpatient Facility Outpatient Surgical Facility Physician’s Services	No charge after the 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. No charge No charge No charge
Routine Foot Disorders	Not covered, except for services associated with foot care for diabetes and peripheral vascular disease, when medically necessary.
Vision Care Eye exam - one per calendar year	No charge
Hardware – per calendar year	Reimbursement allowances: Eyeglasses (including lenses and frames) $75 Contact Lenses $75
Hearing Aid Maximum: $1,000 per 24 months limited to children age 12 and younger	No charge
Bariatric Surgery Treatment of clinically severe obesity; as defined by the body mass index (BMI) is covered only at approved centers. The following will continue to be specifically excluded with this buy-up: Medical and surgical services to alter appearances or physical changes that are the result of any surgery performed for the management of obesity or clinically severe (morbid) obesity. Weight loss programs or treatments, whether prescribed or recommended by a physician or under medical supervision. Physician’s Office Inpatient Facility Outpatient Surgical Facility Physician’s Services	Note: Covered only at approved centers through the pre-certification process. No charge after PCP or Specialist office visit copay; No charge for x-ray/lab if billed by a separate outpatient diagnostic facility such as a hospital. No charge No charge No charge
Prescription Drugs	Carved out to MedImpact
Naturopath Services Office Visit Calendar Year Maximum	90% no deductible $500
Mental Health and Substance Abuse Combined Inpatient Outpatient Outpatient Group Therapy Mental Health and Substance Abuse (One group therapy session equal to one individual therapy session)	No charge No charge after the PCP or Specialist per office visit copay. No charge after the PCP or Specialist per office visit copay.
MH/SA Utilization Review & Case Management	CIGNA Behavioral Health provides utilization review and case management services for In-network Inpatient and Outpatient services only.
Pre-Admission Certification - Continued Stay Review	Coordinated by Provider/PCP
Inpatient Pre-Admission Certification - Continued Stay Review (required for all inpatient admissions)
Case Management	Coordinated by CIGNA Healthcare. This is a service designated to provide assistance to a patient who is at risk of developing medical complexities or for whom a health incident has precipitated a need for rehabilitation or additional health care support. The program strives to attain a balance between quality and cost‑effective care while maximizing the patient’s quality of life.

Medical Benefit Exclusions (by way of example but not limited to):

Your plan provides coverage for medically necessary services. Your plan does not provide coverage for the following except as required by law:

1. Care for health conditions that are required by state or local law to be treated in a public facility.

2. Care required by state or federal law to be supplied by a public school system or school district.

3. Care for military service disabilities treatable through governmental services if you are legally entitled to such treatment and facilities are reasonably available.

4. Treatment of an illness or injury which is due to war, declared or undeclared.

5. Charges for which you are not obligated to pay or for which you are not billed or would not have been billed except that you were covered under this Agreement.

6. Assistance in the activities of daily living, including but not limited to eating, bathing, dressing or other Custodial Services or self-care activities, homemaker services and services primarily for rest, domiciliary or convalescent care.

7. Any services and supplies for or in connection with experimental, investigational or unproven services. Experimental, investigational and unproven services are medical, surgical, diagnostic, psychiatric, substance abuse or other health care technologies, supplies, treatments, procedures, drug therapies or devices that are determined by the Healthplan Medical Director to be: Not demonstrated, through existing peer-reviewed, evidence-based scientific literature to be safe and effective for treating or diagnosing the condition or illness for which its use is proposed; or Not approved by the U.S. Food and Drug Administration (FDA) or other appropriate regulatory agency to be lawfully marketed for the proposed use; or The subject of review or approval by an Institutional Review Board for the proposed use, except as provided in the “Clinical Trials” section of “Section IV. Covered Services and Supplies;” or The subject of an ongoing phase I, II or III clinical trial, except as provided in the “Clinical Trials” section of “Section IV. Covered Services and Supplies.”

8. Cosmetic Surgery and Therapies. Cosmetic surgery or therapy is defined as surgery or therapy performed to improve or alter appearance or self-esteem or to treat psychological symptomatology or psychosocial complaints related to one’s appearance.

9. The following services are excluded from coverage regardless of clinical indications: Macromastia or Gynecomastia Surgeries; Surgical treatment of varicose veins; Abdominoplasty; Panniculectomy; Rhinoplasty; Blepharoplasty; Orthognathic Surgeries; Redundant skin surgery; Removal of skin tags; Acupressure; Craniosacral/cranial therapy; Dance therapy, movement therapy; Applied kinesiology; Rolfing; Prolotherapy; and Extracorporeal shock wave lithotripsy (ESWL) for musculoskeletal and orthopedic conditions.

10. Surgical treatment of TMJ disorder.

11. Dental treatment of the teeth, gums or structures directly supporting the teeth, including dental x-rays, examinations, repairs, orthodontics, periodontics, casts, splints and services for dental malocclusion, for any condition. However, charges made for services or supplies provided for or in connection with an accidental injury to sound natural teeth are covered provided a continuous course of dental treatment is started within 6 months of the accident. Sound natural teeth are defined as natural teeth that are free of active clinical decay, have at least 50% bony support and are functional in the arch.

12. Medical and surgical services to alter appearances or physical changes that are the result of any surgery performed for the management of obesity or clinically severe (morbid) obesity; and weight loss programs or treatments, whether prescribed or recommended by a physician or under medical supervision.

13. Unless otherwise covered as a basic benefit, reports, evaluations, physical examinations, or hospitalization not required for health reasons, including but not limited to employment, insurance or government licenses, and court ordered, forensic, or custodial evaluations.

14. Court ordered treatment or hospitalization, unless such treatment is being sought by a Participating Physician or otherwise covered under "Section IV. Covered Services and Supplies."

15. Infertility services: costs associated with the collection, washing, preparation or storage of sperm for artificial insemination (including donor fees). Cryopreservation of donor sperm and eggs are also excluded from coverage.

16. Reversal of male and female voluntary sterilization procedures.

17. Transsexual surgery, including medical or psychological counseling and hormonal therapy in preparation for, or subsequent to, any such surgery.

18. Any services, supplies, medications or drugs for the treatment of male or female sexual dysfunction such as, but not limited to, treatment of erectile dysfunction (including penile implants), anorgasmia, and premature ejaculation.

19. Medical and hospital care and costs for the infant child of a Dependent, unless this infant child is otherwise eligible under the Agreement.

20. Non-medical counseling or ancillary services, including, but not limited to Custodial Services, education, training, vocational rehabilitation, behavioral training, biofeedback, neurofeedback, hypnosis, sleep therapy, employment counseling, back school, return-to-work services, work hardening programs, driving safety, and services, training, educational therapy or other non-medical ancillary services for learning disabilities, developmental delays, autism or mental retardation.

21. Therapy or treatment intended primarily to improve or maintain general physical condition or for the purpose of enhancing job, school, athletic or recreational performance, including, but not limited to routine, long-term or maintenance care which is provided after the resolution of the acute medical problem and when significant therapeutic improvement is not expected.

22. Consumable medical supplies other than ostomy supplies and urinary catheters. Excluded supplies include, but are not limited to bandages and other disposable medical supplies, skin preparations and test strips, except as specified in the "Inpatient Hospital Services," "Outpatient Facility Services," "Home Health Services" or “Breast Reconstruction and Breast Prostheses” sections of "Section IV. Covered Services and Supplies."

23. Private hospital rooms and/or private duty nursing except as provided in the Home Health Services section of “Section IV. Covered Services and Supplies”.

24. Personal or comfort items such as personal care kits provided on admission to a hospital, television, telephone, newborn infant photographs, complimentary meals, birth announcements, and other articles which are not for the specific treatment of illness or injury.

25. Artificial aids, including but not limited to corrective orthopedic shoes, arch supports, elastic stockings, garter belts, corsets, dentures and wigs.

26. Hearing aids for members age 13 and over, including, but not limited to semi-implantable hearing devices, audiant bone conductors and Bone Anchored Hearing Aids (BAHAs). A hearing aid is any device that amplifies sound.

27. Aids or devices that assist with non-verbal communications, including, but not limited to communication boards, pre-recorded speech devices, laptop computers, desktop computers, Personal Digital Assistants (PDAs), Braille typewriters, visual alert systems for the deaf and memory books.

28. Eye exercises and surgical treatment for the correction of a refractive error, including radial keratotomy.

29. Treatment by acupuncture.

30. All non-injectable prescription drugs, injectable prescription drugs that do not require physician supervision and are typically considered self-administered drugs, non-prescription drugs, and investigational and experimental drugs, except as provided in "Section IV. Covered Services and Supplies.”

31. Routine foot care, including the paring and removing of corns and calluses or trimming of nails. However, services associated with foot care for diabetes and peripheral vascular disease are covered when Medically Necessary.

32. Membership costs or fees associated with health clubs, weight loss programs and smoking cessation programs.

33. Genetic screening or pre-implantation genetic screening. General population-based genetic screening is a testing method performed in the absence of any symptoms or any significant, proven risk factors for genetically-linked inheritable disease.

34. Dental implants for any condition.

35. Fees associated with the collection or donation of blood or blood products, except for autologous donation in anticipation of scheduled services where in the Healthplan Medical Director’s opinion the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery.

36. Blood administration for the purpose of general improvement in physical condition.

37. Cost of biologicals that are immunizations or medications for the purpose of travel, or to protect against occupational hazards and risks.

38. Cosmetics, dietary supplements and health and beauty aids.

39. All nutritional supplements and formulae are excluded, except for infant formula needed for the treatment of inborn errors of metabolism.

40. Expenses incurred for medical treatment when payment is denied by the Primary Plan because treatment was not received from a Participating Provider of the Primary Plan.

41. Services for or in connection with an injury or illness arising out of, or in the course of, any employment for wage or profit.

42. Telephone, e-mail & Internet consultations and telemedicine.

43. Massage Therapy

This Benefit Summary highlights some of the benefits available under your plan. A complete description regarding the terms of coverage, exclusions and limitations, including legislated benefits, will be provided in your Group Service Agreement or Certificate.

Benefits are insured and/or administered by Connecticut General Life Insurance Company.

“CIGNA HealthCare” refers to various operating subsidiaries of CIGNA Corporation. Products and services are provided by these subsidiaries and not by CIGNA Corporation. These subsidiaries include Connecticut General Life Insurance Company, CIGNA Vision Care, Inc., Tel-Drug, Inc. and its affiliates, CIGNA Behavioral Health, Inc., Intracorp, and HMO or service company subsidiaries of CIGNA Health Corporation and CIGNA Dental Health, Inc. "CIGNA Tel-Drug" refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C., which are also operating subsidiaries of CIGNA Corporation.