01/01/2026 ASO Open Access Plus HDHPQ - HDHPQ 3500 Proclaim - 37302326 - V 33 - 10/20/25 05:17 PM ET 3 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. Virtual 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% ^  Physicians may deliver services virtually that are payable under other benefits (e.g., Preventive Care, Outpatient Therapy Services).  Includes charges for the delivery of medical and health-related services and consultations as medically appropriate through audio, video, and secure internet- based technologies that are similar to office visit services provided in a face-to-face setting. 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). Convenience Care Clinic Convenience Care Clinic Plan pays 80% ^ Plan pays 50% ^ Preventive Care Preventive Care Plan pays 100% PCP: Plan pays 50% ^ Specialist: Plan pays 50% ^  Includes coverage of additional services, such as urinalysis, EKG, and other laboratory tests, supplementing the standard Preventive Care benefit when billed as part of office visit.  Annual Limit: Unlimited Immunizations Plan pays 100% PCP: Plan pays 50% ^ Specialist: Plan pays 50% ^ Mammogram, PAP, and PSA Tests Plan pays 100% Covered same as other x-ray and lab services, based on Place of Service  Coverage includes the associated Preventive Outpatient Professional Services.  Diagnostic-related services are covered at the same level of benefits as other x-ray and lab services, based on Place of Service. Inpatient Inpatient Hospital Facility Services Plan pays 80% ^ Plan pays 50% ^ Note: Includes all Lab and Radiology services, including Advanced Radiological Imaging as well as Medical Pharmaceutical Drugs Inpatient Hospital Physician's Visit/Consultation Plan pays 80% ^ Plan pays 50% ^ Inpatient Professional Services Plan pays 80% ^ Plan pays 50% ^  For services performed by Surgeons, Radiologists, Pathologists and Anesthesiologists Outpatient Outpatient Facility Services Plan pays 80% ^ Plan pays 50% ^ Outpatient Professional Services Plan pays 80% ^ Plan pays 50% ^  For services performed by Surgeons, Radiologists, Pathologists and Anesthesiologists