Cigna Health Reimbursement Account (HRA) - K12.com

K12 Inc.CIGNA Choice Fund Health Reimbursement Account Open Access Plus Coinsurance PlanBenefits In-network Out-of-networkEmergency and urgent care servicesHospital emergency room• Includes radiology, pathology and physician charges• Out-of-network services are covered at the in-networkrate.Ambulance• Out-of-network services are covered the same as innetworkservices.Note: Non-emergency transportation (e.g. fromhospital back home) is generally not covered.Urgent care services• Out-of-network services are covered at the in-networkrate.Other health care facilitiesSkilled nursing facility, rehabilitation hospital andother facilities• 100 days per plan yearHome health care• 90 days per plan yearHospice• Inpatient services• Outpatient servicesOther health care servicesDurable medical equipment• Unlimited plan year maximumWigs• Limited to $500 per plan yearExternal prosthetic appliances (EPA)• Unlimited plan year maximumTMJ, Surgical and non-surgical• Doctor’s Office• Inpatient Facility• Outpatient Facility• Physician’s ServicesYou pay 0%Plan pays 100%after the deductible is metYou pay 0%Plan pays 100%after the deductible is metYou pay 0%Plan pays 100%after the deductible is metYou pay 0%Plan pays 100%after the deductible is metYou pay 0%Plan pays 100%after the deductible is metYou pay 0%Plan pays 100%after deductible is metCost and reimbursementvary based on the facility inwhich it is performedYou pay 0%Plan pays 100%after the deductible is metYou pay 0%Plan pays 100%after the deductible is metYou pay 0%Plan pays 100%after the deductible is metYou pay 30%Plan pays 70%after the deductible is metYou pay 30%Plan pays 70%after the deductible is metYou pay 30%Plan pays 70%after the deductible is metYou pay 30%Plan pays 70%after the deductible is metYou pay 30%Plan pays 70%after the deductible is metYou pay 30%Plan pays 70%after deductible is metCost and reimbursementvary based on the facility inwhich it is performed.Infertility treatment Not Covered Not CoveredJanuary 01, 2012VirginiaPage 4 of 8