COLORADO HEALTH PLAN DESCRIPTION FORM - Cigna

Preventive DrugsPreventive Drugs designated by thePatient Protection and Affordable CareAct of 2010IN-NETWORKPlan pays 100% (deductible waived)OUT-OF-NETWORKNot availableGeneric(except as noted underPreventive Drugs)BrandNon-preferredSelf Injectable12. INPATIENT HOSPITALOpen Access Value 1500/70%Open Access Value 2500/70%Open Access Value 3000/70%Open Access Value 5000/70%Open Access Value 7500/70%Open Access Value 10,000/70%$40 copay Not available$100 copay (subject to brand name drug deductible) Not available$165 copay (subject to brand name drug deductible) Not available30% coinsurance Not available$500 additional deductible peradmission, (does not apply to out-ofpocketmaximum), 30% coinsurance$1,000 additional deductible peradmission, (does not apply to out-ofpocketmaximum), 50% coinsuranceOpen Access Value 5000/100%13. OUTPATIENT/AMBULATORYSURGERYOpen Access Value 1500/70%Open Access Value 2500/70%Open Access Value 3000/70%Open Access Value 5000/70%Open Access Value 7500/70%Open Access Value 10,000/70%Open Access Value 5000/100%14. DIAGNOSTICSa) Laboratory & X-rayOpen Access Value 1500/70%Open Access Value 2500/70%Open Access Value 3000/70%Open Access Value 5000/70%Open Access Value 7500/70%Open Access Value 10,000/70%Open Access Value 5000/100%$500 additional deductible peradmission, (does not apply to out-ofpocketmaximum), 0% coinsurance30% coinsurance0% coinsurance30% coinsurance (in any setting)0% coinsurance (in any setting)$1,000 additional deductible peradmission, (does not apply to out-ofpocketmaximum), 50% coinsurance50% coinsurance50% coinsurance50% coinsurance (in any setting)50% coinsurance (in any setting)b) MRI, nuclear medicine, CT, CTA,MRA, and PET scansOpen Access Value 1500/70%Open Access Value 2500/70%Open Access Value 3000/70%Open Access Value 5000/70%Open Access Value 7500/70%Open Access Value 10,000/70%Open Access Value 5000/100%30% coinsurance (in any setting)0% coinsurance (in any setting)50% coinsurance (in any setting)50% coinsurance (in any setting)CO_Individual Open Access Value Plans Page 4 of 15Catalog No: 851836a CO 8/12