Cigna Health Reimbursement Account (HRA) - K12.com

K12 Inc.CIGNA Choice Fund Health Reimbursement Account Open Access Plus Coinsurance PlanBenefits In-network Out-of-networkFamily planning• Inpatient hospital facility• Outpatient facility• Physician services• Surgical services such as tubal ligation or vasectomyare covered (excluding reversals).• Includes contraceptive devicesMental health and substance abuse servicesYou pay 0%Plan pays 100%after the deductible is metYou pay 30%Plan pays 70%after the deductible is metPlease note the following regarding Mental Health (MH) and Substance Abuse (SA) benefit administration:• Substance Abuse includes Alcohol and Drug Abuse services.• Transition of Care benefits are provided for a 90-day time period.Inpatient mental health services• Unlimited days per plan year• Mental health services are paid at 100% after youreach your out-of-pocket maximum.Outpatient mental health physician’s office andoutpatient facility services• Unlimited visits per plan year• Mental health services are paid at 100% after youreach your out-of-pocket maximum.• This includes group therapy mental health, andintensive outpatient mental healthInpatient substance abuse services• Unlimited days per plan year• Substance abuse services are paid at 100% after youreach your out-of-pocket maximum.Outpatient substance abuse physician’s office andoutpatient facility services• Unlimited visits per plan year• Substance abuse services are paid at 100% after youreach your out-of-pocket maximum.• This includes intensive outpatient substance abuseYou 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 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 metJanuary 01, 2012VirginiaPage 5 of 8