This is a summary of benefits for your Open Access Plus plan. All deductibles and plan out-of-pocket maximums accumulate in one direction toward in-network unless otherwise noted. Plan maximums and service-specific maximums (dollar and occurrence) cross-accumulate between in- and out-of-network unless otherwise noted.

CIGNA HealthCare Benefit Summary

Wesleyan University

2007 Open Access Plus Copay Plan

Point of Service

BENEFIT HIGHLIGHTS	IN-NETWORK	OUT-OF-NETWORK
Lifetime Maximum	Unlimited	Unlimited
Coinsurance Levels	100%	80% of Reasonable & Customary
Calendar Year Deductible Individual Family Maximum Aggregate	N/A N/A N/A	$250 per person $500 per family Yes
Out-of-Pocket Maximum
Includes Deductible	N/A	Yes
Includes Copays Does not apply to	N/A Non-compliance penalties, deductibles, copays or charges for mental health, alcohol and drug abuse benefits.	No Non-compliance penalties, copays or charges for mental health, alcohol and drug abuse benefits or charges in excess of Reasonable and Customary
Individual	N/A	$1,250 per person
Family Maximum	N/A	$2,500 per family
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 office visit copay if only x-ray and/or lab services performed and billed.	80% after plan deductible
Specialty Care Physician's Office Visit Office Visits Consultant and Referral Physician's Services Note: 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.	80% after plan deductible
Surgery Performed In the Physician's Office	No charge after PCP or Specialist per office visit copay	80% after plan deductible
Second Opinion Consultations (services will be provided on a voluntary basis)	No charge after the PCP or Specialist per office visit copay	80% after plan deductible
Allergy Treatment/Injections	No charge after either the PCP or Specialist per office visit copay or the actual charge, whichever is less	80% after plan deductible
Allergy Serum (dispensed by the physician in the office)	No charge	80% after plan deductible
Preventive Care Routine Preventive Care: Well baby; Well Child, Adult & Well Woman	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.	80% after plan deductible
Immunizations	No charge	80% after plan deductible
Note: OB-GYN visits will be subject to the plan's PCP copay.
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	80% after plan deductible
Inpatient Hospital - Facility Services	No charge	80% after plan deductible Precertification required
Semi Private Room and Board	Limited to semi-private room negotiated rate	Limited to semi-private room rate
Private Room	Limited to semi-private room negotiated rate	Limited to semi-private room rate
Special Care Units (ICU/CCU)	Limited to negotiated rate	Limited ICU/CCU daily room rate
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	80% after plan deductible
Inpatient Hospital Physician’s Visits/Consultations	No charge	80% after plan deductible
Inpatient Hospital Professional Services Surgeon Radiologist Pathologist Anesthesiologist	No charge	80% after plan deductible
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.	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	80% after plan deductible
Emergency and Urgent Care Services 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 lab services performed	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 lab services performed (except if not a true emergency, then 80% after plan deductible).
Hospital Emergency Room	No charge after $50 per visit copay*	No charge after $50 per visit copay* (except if not a true emergency, then 80% after plan deductible).
Outpatient Professional services (radiology, pathology and ER Physician)	No charge	No charge (except if not a true emergency, then 80% after plan deductible).
Urgent Care Facility or Outpatient Facility	No charge after $25 per visit copay*	No charge after $25 per visit copay* (except if not a true emergency, then 80% after plan deductible).
Ambulance	No charge**	No charge** (except if not a true emergency, then 80% after plan deductible).