01/01/2026 ASO Open Access Plus HDHPQ - HDHPQ 3500 Proclaim - 37302326 - V 33 - 10/20/25 05:17 PM ET 5 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. Outpatient Therapy Services Outpatient Therapy Services Covered same as Physician Services - Office Visit Covered same as Physician Services - Office Visit Annual Limits:  All Therapies Combined - Includes Cognitive Therapy, Occupational Therapy, Physical Therapy, Pulmonary Rehabilitation, and Speech Therapy - Unlimited days Note: Therapy days, provided as part of an approved Home Health Care plan, accumulate to the applicable outpatient therapy services maximum. Chiropractic Services Covered same as Physician Services - Office Visit Covered same as Physician Services - Office Visit Annual Limit:  Chiropractic Care - 12 days Cardiac Rehabilitation Services Covered same as Physician Services - Office Visit Covered same as Physician Services - Office Visit Annual Limit:  Cardiac Rehabilitation - 36 days Hospice Inpatient Facilities Plan pays 80% ^ Plan pays 50% ^ Outpatient Services Plan pays 80% ^ Plan pays 50% ^ Note: Includes Bereavement counseling provided as part of a hospice program. Bereavement Counseling (for services not provided as part of a hospice program) Services Provided by a Mental Health Professional Covered under Mental Health benefit Covered under Mental Health benefit Medical Pharmaceutical Drugs Cigna Pathwell Specialty® Medical Pharmaceuticals Plan pays 80% ^ Not Covered Other Medical Pharmaceuticals Plan pays 80% ^ Plan pays 50% ^  Cigna Pathwell Specialty® Medical Pharmaceuticals are only covered when administered by a Cigna Pathwell Specialty® designated provider.  This benefit only applies to the cost of Medical Pharmaceutical drugs administered. Related Facility, Office Visit or Professional charges are covered according to the plan design.