COLORADO HEALTH PLAN DESCRIPTION FORM - Cigna

Open Access Value 10,000/70%IN-NETWORKOUT-OF-NETWORKOpen Access Value 5000/100%0% coinsurance 50% coinsurance(Maximum 12 visits per person, per year,in-and out-of-network combined, allservices combined.)22. DURABLE MEDICALEQUIPMENTOpen Access Value 1500/70% 30% coinsurance (in any setting) 50% coinsurance (in any setting)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%0% coinsurance (in any setting)50% coinsurance (in any setting)23. OXYGEN Included under Durable Medical Equipment.24. ORGAN TRANSPLANTS(Prior authorization required. Coveredtransplants include: liver, heart,heart/lung, lung, kidney, kidney/pancreasother single and multi-organ transplants,and autologous and allogenic bonemarrow, peripheral stem cell transplantand similar procedures.)Open 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%25. HOME HEALTH CAREOpen 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%(Maximum 60 visits per person, per year,in- and out-of-network combined.)26. HOSPICE CAREa) Routine Home CareCigna Lifesource ® Transplant NetworkFacilityPlan pays 100% plus $10,000 travelbenefit per person, per lifetimeNon-Lifesource ® in-network facility30% coinsurance, travel benefitexcludedCigna Lifesource ® Transplant NetworkFacilityPlan pays 100% plus $10,000 travelbenefit per person, per lifetimeNon-Lifesource ® in-network facilityPlan pays 100%, travel benefit excluded30% coinsurance0% coinsuranceNot coveredNot covered50% coinsurance50% coinsuranceCO_Individual Open Access Value Plans Page 6 of 15Catalog No: 851836a CO 8/12