01/01/2026 ASO Open Access Plus HDHPQ - HDHPQ 3500 Proclaim - 37302326 - V 33 - 10/20/25 05:17 PM ET 2 of 17 ©Cigna 2025 Plan Highlights In-Network Out-of-Network Plan Out-of-Pocket Maximum Individual - Employee Only: $5,000 Individual - within a Family: $5,000 Family Maximum: $10,000 Individual - Employee Only: $10,000 Individual - within a Family: $10,000 Family Maximum: $20,000  Only the amount you pay for in-network covered expenses counts toward your in-network out-of-pocket maximum. Only the amount you pay for out-of- network covered expenses counts toward your out-of-network out-of-pocket maximum.  Plan deductible contributes towards your out-of-pocket maximum.  All benefit copays/deductibles contribute towards your out-of-pocket maximum.  Covered expenses that count towards your out-of-pocket maximum include customer paid coinsurance and charges for Mental Health and Substance Use Disorder. Out-of-network non-compliance penalties or charges in excess of Maximum Reimbursable Charge do not contribute towards the out-of-pocket maximum.  After each eligible family member meets his or her individual out-of-pocket maximum, the plan will pay 100% of their covered expenses. Or, after the family out-of-pocket maximum has been met, the plan will pay 100% of each eligible family member's covered expenses.  This plan includes a combined Medical/Pharmacy out-of-pocket maximum. 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. Physician Services - Office Visits Primary Care Physician (PCP) Services/Office Visit Plan pays 80% ^ Plan pays 50% ^ Specialty Care Physician Services/Office Visit Plan pays 80% ^ Plan pays 50% ^ NOTE: Obstetrician and Gynecologist (OB/GYN) visits are subject to either the PCP or Specialist cost share depending on how the provider contracts with Cigna (i.e. as PCP or as Specialist). Surgery Performed in Physician's Office Covered same as Physician Services - Office Visit Covered same as Physician Services - Office Visit Allergy Treatment/Injections and Allergy Serum Allergy serum dispensed by the physician in the office Covered same as Physician Services - Office Visit Covered same as Physician Services - Office Visit Virtual Care Dedicated Virtual Providers - MDLIVE MDLIVE Urgent Virtual Care Services Plan pays 80% ^ Not Covered MDLIVE Primary Care Services Plan pays 80% ^ Not Covered MDLIVE Specialty Care Services Plan pays 80% ^ Not Covered  Primary Care cost share applies to routine care. Virtual wellness screenings are payable under Preventive Care.  For MDLIVE Behavioral Services, please refer to the Mental Health and Substance Use Disorder section (below).  Lab services supporting a virtual visit must be obtained through dedicated labs.  Includes charges for the delivery of medical and health-related services and consultations by dedicated virtual providers as medically appropriate through audio, video, and secure internet-based technologies.