01/01/2026 ASO Open Access Plus HDHPQ - HDHPQ 3500 Proclaim - 37302326 - V 33 - 10/20/25 05:17 PM ET 9 of 17 ©Cigna 2025 Benefit In-Network Out-of-Network Note: Services where plan deductible applies are noted with a caret (^). Plan deductible always applies before benefit copays/deductibles. Mental Health and Substance Use Disorder Inpatient Mental Health Plan pays 80% ^ Plan pays 50% ^ Outpatient Mental Health – Physician’s Office Plan pays 80% ^ Plan pays 50% ^ Outpatient Mental Health - MDLIVE Behavioral Services Plan pays 80% ^ Not Covered Outpatient Mental Health – All Other Services Plan pays 80% ^ Plan pays 50% ^ Inpatient Substance Use Disorder Plan pays 80% ^ Plan pays 50% ^ Outpatient Substance Use Disorder – Physician’s Office Plan pays 80% ^ Plan pays 50% ^ Outpatient Substance Use Disorder - MDLIVE Behavioral Services Plan pays 80% ^ Not Covered Outpatient Substance Use Disorder – All Other Services Plan pays 80% ^ Plan pays 50% ^ Annual Limits:  Unlimited maximum Notes:  Inpatient includes Acute Inpatient and Residential Treatment.  Outpatient - Physician's Office and MDLIVE Behavioral Services - may include Individual, family and group therapy, psychotherapy, medication management, etc.  Outpatient - All Other Services - may include Partial Hospitalization, Intensive Outpatient Services, Applied Behavior Analysis (ABA Therapy), etc.  Services are paid at 100% after you reach your out-of-pocket maximum. Important Note on Mental Health and Substance Use Disorder Coverage: Covered medical services listed above, which are received to diagnose or treat a Mental Health or Substance Use Disorder condition will be payable according to this section titled “Mental Health and Substance Use Disorder.” Mental Health/Substance Use Disorder Utilization Review, Case Management and Programs Cigna Total Behavioral Health - Inpatient and Outpatient Management  Inpatient utilization review and case management  Outpatient utilization review and case management  Partial Hospitalization  Intensive outpatient programs  Changing Lives by Integrating Mind and Body Program  Lifestyle Management Programs: Stress Management, Tobacco Cessation and Weight Management.  Narcotic Therapy Management  inMynd℠ program - a comprehensive, holistic solution to help recognize and find resources to treat behavioral health conditions.