2021 Cigna Connect Bronze Options
Cigna Connect Bronze Overview
Bronze plans usually have the lowest monthly premiums but the highest costs when you get care. These plans are good for individuals that usually use few medical services, don’t see a doctor often, and mostly want protection from very high costs if they get seriously sick or injured.
| Plan Name | Cigna Connect -0 | Cigna Connect 6750 | Cigna Connect 7150 | Cigna Connect 8550 |
| Deductible | $0 | $6,750/$13,500 | $7,150/$14,000 | $8,550/$17,100 |
| Coinsurance | 0% | 50% | 50% | 0% |
| Out-of-Pocket Maximum | $8,550/$17,100 | $8,550/$17,100 | $8,550/$17,100 | $8,550/$17,100 |
| PCP/Specialist | 0% | $50/$90 | 50% | 0% |
Cigna Connect-0
| Important Questions | Answers | Why this Matters: |
| What is the overall deductible? | $0 person/ $0 family | See the Common Medical Events chart below for your costs for services this plan covers |
| Are there services covered before you meet your deductible? | Yes. | This plan covers some items and services even if you haven’t yet met the deductible amount |
| Are there other deductibles for specific services? |
No | You don’t have to meet deductibles for specific services |
| What is the out-of-pocket limit for this plan? |
$0 person/ $0 family | This plan does not have an out-of-pocket limit on your expenses |
| What is not included in the out-of-pocket limit? |
Premiums, balance-billing charges, penalties for failure to obtain preauthorization for services and health care this plan doesn’t cover. |
This plan does not have an out-of-pocket limit on your expenses |
| Will you pay less if you use a network provider? | Yes. See www.cigna.com/ifpproviders or call 1-866-494-2111 for a list of network providers. |
This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. |
| Do you need a referral to see a specialist? | Yes | This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist. |
| Common Medical Event | Services You May Need |
Your cost if you use |
Your cost if you use |
Limitations & Exceptions, & Other Important Information |
| If you visit a health care provider’s office or clinic | Primary care visit to treat an injury or illness |
No Charge. Includes |
Not covered |
Refer to the policy for more information about Virtual Care Services. |
| Specialist visit |
No Charge |
Not covered |
None | |
| Preventive care/screening/immunization |
No charge |
Not covered |
You may have to pay for services that aren’t preventive. Ask your provider if the services are needed are preventive. Then check what your plan will pay for. | |
| If you have a test | Diagnostic test (x-ray, blood work) |
No Charge |
Not covered |
None |
| Imaging (CT / PET scans, MRIs) |
No Charge |
Not covered |
None | |
| If you need drugs to treat your illness or condition. More information about prescription drug coverage is available at www.cigna.com/ifpdrug-list |
Preferred generic drugs |
No charge (retail/home |
Not covered | Limited to a 30 day supply at any participating pharmacy or up to a 90 day supply at a designated 90 day retail pharmacy/home delivery. |
| Generic drugs |
No charge (retail/home |
Not covered | ||
| Preferred brand drugs |
No charge (retail/home |
Not covered |
||
| Non-preferred drugs |
No charge (retail/home |
Not covered |
||
| Specialty drugs and other high cost drugs | No charge (retail/home delivery) |
Not covered | ||
| If you have outpatient surgery |
Facility fee (e.g., ambulatory surgery center) | No Charge |
Not covered |
None |
| Physician/surgeon fees |
No Charge |
Not covered |
||
| If you need immediate medical attention |
Emergency room care |
No Charge |
No Charge |
You pay the same level as In-network if it is an emergency as defined in your plan, otherwise not covered. |
| Emergency medical transportation |
No Charge |
No Charge |
You pay the same level as In-network if it is an emergency as defined in your plan, otherwise not covered. | |
| Urgent care |
No Charge |
No Charge |
You pay the same level as In-network if it is an emergency as defined in your plan, otherwise not covered. | |
| If you have a hospital stay |
Facility fee (e.g., hospital room) |
No Charge |
Not covered |
None |
| Physician/surgeon fee |
No Charge |
Not covered |
||
| If you have mental health, behavioral health, or substance abuse needs |
Outpatient services | No Charge |
Not covered |
None |
| Inpatient services |
No Charge |
Not covered |
None | |
| If you are pregnant | Office visits |
No Charge |
Not covered |
Cost sharing does not apply for preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). |
| Childbirth/delivery professional services |
No Charge |
Not covered |
Cost sharing does not apply for preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). | |
| Childbirth/delivery facility services |
No Charge |
Not covered |
Cost sharing does not apply for preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). | |
| If you need help recovering or have other special health needs |
Home health care |
No Charge |
Not covered |
None
Cardiac – Limited to a maximum of 36
None
None |
| Rehabilitation services |
No Charge |
Not covered |
||
| Habilitation services |
No Charge |
Not covered |
||
| Skilled nursing care |
No Charge |
Not covered |
||
| Durable medical equipment |
No Charge |
Not covered |
None | |
| Hospice service | No Charge |
Not covered |
None | |
| If your child needs dental or eye care |
Children’s eye exam |
No Charge |
Not covered |
Children up to age 19. Coverage limited to one exam/year |
| Children’s glasses |
No Charge |
Not covered |
Children up to age 19. Coverage limited to one pair of glasses/year. | |
| Children’s dental check-up |
Not Covered |
Not Covered |
Coverage is available through a stand-alone dental policy |
Excluded Services & Other Covered Services:
| Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) |
|
| Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) |
|
Cigna Connect 8550
| Important Questions | Answers | Why this Matters: |
| What is the overall deductible? | $8,550 person/ $17,100 family | Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. |
| Are there services covered before you meet your deductible? | Yes. Preventive care and eye exam/glasses for children are covered before you meet your deductible. |
This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. |
| Are there other deductibles for specific services? |
No | You don’t have to meet deductibles for specific services |
| What is the out-of-pocket limit for this plan? |
$8,550 person/ $17,100 family | The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. |
| What is not included in the out-of-pocket limit? |
Premiums, balance-billing charges, penalties for failure to obtain preauthorization for services and health care this plan doesn’t cover. | Even though you pay these expenses, they don’t count toward the out-of-pocket limit. |
| Will you pay less if you use a network provider? | Yes. See www.cigna.com/ifpproviders or call 1-866-494-2111 for a list of network providers. |
This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. |
| Do you need a referral to see a specialist? |
Yes | This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist. |
| Common Medical Event | Services You May Need |
Your cost if you use |
Your cost if you use |
Limitations & Exceptions, & Other Important Information |
| If you visit a health care provider’s office or clinic | Primary care visit to treat an injury or illness |
0% coinsurance. Virtual |
Not covered |
Refer to the policy for more information about Virtual Care Services. |
| Specialist visit |
0% coinsurance |
Not covered |
None | |
| Preventive care/screening/immunization |
No charge |
Not covered |
You may have to pay for services that aren’t preventive. Ask your provider if the services are needed are preventive. Then check what your plan will pay for. | |
| If you have a test | Diagnostic test (x-ray, blood work) |
0% coinsurance |
Not covered |
None |
| Imaging (CT / PET scans, MRIs) |
0% coinsurance |
Not covered |
None | |
| If you need drugs to treat your illness or condition. More information about prescription drug coverage is available at www.cigna.com/ifpdrug-list |
Preferred generic drugs |
0% coinsurance |
Not covered | Limited to a 30 day supply at any participating pharmacy or up to a 90 day supply at a designated 90 day retail pharmacy/home delivery. |
| Generic drugs |
0% coinsurance |
Not covered | ||
| Preferred brand drugs |
0% coinsurance |
Not covered |
||
| Non-preferred drugs |
0% coinsurance |
Not covered |
||
| Specialty drugs and other high cost drugs | 0% coinsurance (retail/home delivery) |
Not covered | ||
| If you have outpatient surgery |
Facility fee (e.g., ambulatory surgery center) | 0% coinsurance |
Not covered |
None |
| Physician/surgeon fees |
0% coinsurance |
Not covered |
||
| If you need immediate medical attention |
Emergency room care |
0% coinsurance |
0% coinsurance |
You pay the same level as In-network if it is an emergency as defined in your plan, otherwise not covered. |
| Emergency medical transportation |
0% coinsurance |
0% coinsurance |
You pay the same level as In-network if it is an emergency as defined in your plan, otherwise not covered. | |
| Urgent care |
0% coinsurance |
0% coinsurance |
You pay the same level as In-network if it is an emergency as defined in your plan, otherwise not covered. | |
| If you have a hospital stay |
Facility fee (e.g., hospital room) |
0% coinsurance |
Not covered |
None |
| Physician/surgeon fee |
0% coinsurance |
Not covered |
||
| If you have mental health, behavioral health, or substance abuse needs |
Outpatient services | 0% coinsurance |
Not covered |
None |
| Inpatient services |
0% coinsurance |
Not covered |
None | |
| If you are pregnant | Office visits |
0% coinsurance |
Not covered |
Cost sharing does not apply for preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). |
| Childbirth/delivery professional services |
0% coinsurance |
Not covered |
Cost sharing does not apply for preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). | |
| Childbirth/delivery facility services |
0% coinsurance |
Not covered |
Cost sharing does not apply for preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). | |
| If you need help recovering or have other special health needs |
Home health care |
0% coinsurance |
Not covered |
None
Cardiac – Limited to a maximum of 36
None
None |
| Rehabilitation services |
0% coinsurance |
Not covered |
||
| Habilitation services |
0% coinsurance |
Not covered |
||
| Skilled nursing care |
0% coinsurance |
Not covered |
||
| Durable medical equipment |
50% coinsurance |
Not covered |
None | |
| Hospice service | 50% coinsurance |
Not covered |
None | |
| If your child needs dental or eye care |
Children’s eye exam |
No Charge |
Not covered |
Children up to age 19. Coverage limited to one exam/year |
| Children’s glasses |
No Charge |
Not covered |
Children up to age 19. Coverage limited to one pair of glasses/year. | |
| Children’s dental check-up | Not Covered | Not Covered | Coverage is available through a stand-alone dental policy |
Excluded Services & Other Covered Services:
| Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) |
|
| Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) |
|
Cigna Connect 7150
| Important Questions | Answers | Why this Matters: |
| What is the overall deductible? | $7,150 person/ $14,300 family | Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. |
| Are there services covered before you meet your deductible? | Yes. Preventive care and eye exam/glasses for children are covered before you meet your deductible. |
This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. |
| Are there other deductibles for specific services? |
No | You don’t have to meet deductibles for specific services |
| What is the out-of-pocket limit for this plan? |
$8,550 person/ $17,100 family | The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. |
| What is not included in the out-of-pocket limit? |
Premiums, balance-billing charges, penalties for failure to obtain preauthorization for services and health care this plan doesn’t cover. | Even though you pay these expenses, they don’t count toward the out-of-pocket limit. |
| Will you pay less if you use a network provider? | Yes. See www.cigna.com/ifpproviders or call 1-866-494-2111 for a list of network providers. |
This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. |
| Do you need a referral to see a specialist? |
Yes | This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist. |
| Common Medical Event | Services You May Need |
Your cost if you use |
Your cost if you use |
Limitations & Exceptions, & Other Important Information |
| If you visit a health care provider’s office or clinic | Primary care visit to treat an injury or illness |
50% coinsurance. Virtual |
Not covered |
Refer to the policy for more information about Virtual Care Services. |
| Specialist visit |
50% coinsurance |
Not covered |
None | |
| Preventive care/screening/immunization |
No charge |
Not covered |
You may have to pay for services that aren’t preventive. Ask your provider if the services are needed are preventive. Then check what your plan will pay for. | |
| If you have a test | Diagnostic test (x-ray, blood work) |
50% coinsurance |
Not covered |
None |
| Imaging (CT / PET scans, MRIs) |
50% coinsurance |
Not covered |
None | |
| If you need drugs to treat your illness or condition. More information about prescription drug coverage is available at www.cigna.com/ifpdrug-list |
Preferred generic drugs |
50% coinsurance |
Not covered | Limited to a 30 day supply at any participating pharmacy or up to a 90 day supply at a designated 90 day retail pharmacy/home delivery. |
| Generic drugs |
50% coinsurance |
Not covered | ||
| Preferred brand drugs |
40% coinsurance |
Not covered |
||
| Non-preferred drugs |
50% coinsurance |
Not covered |
||
| Specialty drugs and other high cost drugs | 50% coinsurance (retail/home delivery) |
Not covered | ||
| If you have outpatient surgery |
Facility fee (e.g., ambulatory surgery center) | 50% coinsurance |
Not covered |
None |
| Physician/surgeon fees |
50% coinsurance |
Not covered |
||
| If you need immediate medical attention |
Emergency room care |
50% coinsurance |
50% coinsurance |
You pay the same level as In-network if it is an emergency as defined in your plan, otherwise not covered. |
| Emergency medical transportation |
50% coinsurance |
50% coinsurance |
You pay the same level as In-network if it is an emergency as defined in your plan, otherwise not covered. | |
| Urgent care |
50% coinsurance |
50% coinsurance |
You pay the same level as In-network if it is an emergency as defined in your plan, otherwise not covered. | |
| If you have a hospital stay |
Facility fee (e.g., hospital room) |
50% coinsurance |
Not covered |
None |
| Physician/surgeon fee |
50% coinsurance |
Not covered |
||
| If you have mental health, behavioral health, or substance abuse needs |
Outpatient services | 50% coinsurance |
Not covered |
None |
| Inpatient services |
50% coinsurance |
Not covered |
None | |
| If you are pregnant | Office visits |
50% coinsurance |
Not covered |
Cost sharing does not apply for preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). |
| Childbirth/delivery professional services |
50% coinsurance |
Not covered |
Cost sharing does not apply for preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). | |
| Childbirth/delivery facility services |
50% coinsurance |
Not covered |
Cost sharing does not apply for preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). | |
| If you need help recovering or have other special health needs |
Home health care |
50% coinsurance |
Not covered |
None
Cardiac – Limited to a maximum of 36
None
None |
| Rehabilitation services |
50% coinsurance |
Not covered |
||
| Habilitation services |
50% coinsurance |
Not covered |
||
| Skilled nursing care |
50% coinsurance |
Not covered |
||
| Durable medical equipment |
50% coinsurance |
Not covered |
None | |
| Hospice service | 50% coinsurance |
Not covered |
None | |
| If your child needs dental or eye care |
Children’s eye exam |
No Charge |
Not covered |
Children up to age 19. Coverage limited to one exam/year |
| Children’s glasses |
No Charge |
Not covered |
Children up to age 19. Coverage limited to one pair of glasses/year. | |
| Children’s dental check-up | Not Covered | Not Covered | Coverage is available through a stand-alone dental policy |
Excluded Services & Other Covered Services:
| Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) |
|
| Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) |
|
Cigna Connect 6750
| Important Questions | Answers | Why this Matters: |
| What is the overall deductible? | $6,750 person/ $13,500 family | Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. |
| Are there services covered before you meet your deductible? | Yes. Preventive care, office visits subject to a copayment, Urgent care and eye exam/glasses for children are covered before you meet your deductible. |
This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. |
| Are there other deductibles for specific services? |
No | You don’t have to meet deductibles for specific services |
| What is the out-of-pocket limit for this plan? |
$8,550 person/ $17,100 family | The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. |
| What is not included in the out-of-pocket limit? |
Premiums, balance-billing charges, penalties for failure to obtain preauthorization for services and health care this plan doesn’t cover. | Even though you pay these expenses, they don’t count toward the out-of-pocket limit. |
| Will you pay less if you use a network provider? | Yes. See www.cigna.com/ifpproviders or call 1-866-494-2111 for a list of network providers. |
This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. |
| Do you need a referral to see a specialist? |
Yes | This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist. |
| Common Medical Event | Services You May Need |
Your cost if you use |
Your cost if you use |
Limitations & Exceptions, & Other Important Information |
| If you visit a health care provider’s office or clinic | Primary care visit to treat an injury or illness |
$50 copayment/visit; |
Not covered |
Refer to the policy for more information about Virtual Care Services. |
| Specialist visit |
$90 copayment/visit |
Not covered |
None | |
| Preventive care/screening/immunization |
No charge |
Not covered |
You may have to pay for services that aren’t preventive. Ask your provider if the services are needed are preventive. Then check what your plan will pay for. | |
| If you have a test | Diagnostic test (x-ray, blood work) |
50% coinsurance |
Not covered |
None |
| Imaging (CT / PET scans, MRIs) |
50% coinsurance |
Not covered |
None | |
| If you need drugs to treat your illness or condition. More information about prescription drug coverage is available at www.cigna.com/ifpdrug-list |
Preferred generic drugs |
50% coinsurance |
Not covered | Limited to a 30 day supply at any participating pharmacy or up to a 90 day supply at a designated 90 day retail pharmacy/home delivery. |
| Generic drugs |
50% coinsurance |
Not covered | ||
| Preferred brand drugs |
40% coinsurance |
Not covered |
||
| Non-preferred drugs |
50% coinsurance |
Not covered |
||
| Specialty drugs and other high cost drugs | 50% coinsurance (retail/home delivery) |
Not covered | ||
| If you have outpatient surgery |
Facility fee (e.g., ambulatory surgery center) | 50% coinsurance |
Not covered |
None |
| Physician/surgeon fees |
50% coinsurance |
Not covered |
||
| If you need immediate medical attention |
Emergency room care |
$1000 copayment/visit |
$1000 copayment/visit |
You pay the same level as In-network if it is an emergency as defined in your plan, otherwise not covered. |
| Emergency medical transportation |
50% coinsurance |
50% coinsurance |
You pay the same level as In-network if it is an emergency as defined in your plan, otherwise not covered. | |
| Urgent care |
$50 copayment /visit; |
$50 copayment /visit; |
You pay the same level as In-network if it is an emergency as defined in your plan, otherwise not covered. | |
| If you have a hospital stay |
Facility fee (e.g., hospital room) |
50% coinsurance |
Not covered |
None |
| Physician/surgeon fee |
50% coinsurance |
Not covered |
||
| If you have mental health, behavioral health, or substance abuse needs |
Outpatient services | $50 copayment / office visit; deductible does not apply and 50% coinsurance other outpatient services |
Not covered |
None |
| Inpatient services |
50% coinsurance |
Not covered |
None | |
| If you are pregnant | Office visits |
50% coinsurance |
Not covered |
Cost sharing does not apply for preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). |
| Childbirth/delivery professional services |
50% coinsurance |
Not covered |
Cost sharing does not apply for preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). | |
| Childbirth/delivery facility services |
50% coinsurance |
Not covered |
Cost sharing does not apply for preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). | |
| If you need help recovering or have other special health needs |
Home health care |
50% coinsurance |
Not covered |
None
Cardiac – Limited to a maximum of 36
None
None |
| Rehabilitation services |
50% coinsurance |
Not covered |
||
| Habilitation services |
50% coinsurance |
Not covered |
||
| Skilled nursing care |
50% coinsurance |
Not covered |
||
| Durable medical equipment |
50% coinsurance |
Not covered |
None | |
| Hospice service | 50% coinsurance |
Not covered |
None | |
| If your child needs dental or eye care |
Children’s eye exam |
No Charge |
Not covered |
Children up to age 19. Coverage limited to one exam/year |
| Children’s glasses |
No Charge |
Not covered |
Children up to age 19. Coverage limited to one pair of glasses/year. | |
| Children’s dental check-up | Not Covered | Not Covered | Coverage is available through a stand-alone dental policy |
Excluded Services & Other Covered Services:
| Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) |
|
| Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) |
|
