01/01/2026 ASO Open Access Plus HDHPQ - HDHPQ 3500 Proclaim - 37302326 - V 33 - 10/20/25 05:17 PM ET 4 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. Emergency Services Emergency Room  Includes Professional, X-ray and/or Lab services performed at the Emergency Room and billed by the facility as part of the ER visit. Plan pays 80% ^ Plan pays 80% ^ Urgent Care Facility  Includes Professional, X-ray and/or Lab services performed at the Urgent Care Facility and billed by the facility as part of the urgent care visit. Plan pays 80% ^ Plan pays 50% ^ Ambulance Plan pays 80% ^ Plan pays 80% ^ Ambulance services used as non-emergency transportation (e.g., transportation from hospital back home) generally are not covered. Ambulance - Mental Health and Substance Use Disorder Plan pays 80% ^ Plan pays 80% ^ Ambulance services used as non-emergency transportation (e.g., transportation from hospital back home) generally are not covered. Inpatient Services at Other Health Care Facilities Skilled Nursing Facility, Rehabilitation Hospital, Sub-Acute Facilities  Annual Limit: 60 days Plan pays 80% ^ Plan pays 50% ^ Laboratory Services Physician’s Services/Office Visit Covered same as Physician Services - Office Visit Covered same as Physician Services - Office Visit Independent Lab Plan pays 80% ^ Plan pays 50% ^ Outpatient Facility Plan pays 80% ^ Plan pays 50% ^ Radiology Services Physician’s Services/Office Visit Covered same as Physician Services - Office Visit Covered same as Physician Services - Office Visit Outpatient Facility Plan pays 80% ^ Plan pays 50% ^ Advanced Radiological Imaging (ARI) Includes MRI, MRA, CAT Scan, PET Scan, etc. Outpatient Facility Plan pays 80% ^ Plan pays 50% ^ Physician’s Services/Office Visit Covered same as Physician Services - Office Visit Covered same as Physician Services - Office Visit