01/01/2026 ASO Open Access Plus HDHPQ - HDHPQ 4500 Proclaim - 37302329 - V 33 - 10/20/25 05:26 PM ET 6 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. Maternity Initial Visit to Confirm Pregnancy Covered same as Physician Services - Office Visit Covered same as Physician Services - Office Visit All Subsequent Prenatal Visits, Postnatal Visits and Physician's Delivery Charges (Global Maternity Fee) Plan pays 80% ^ Plan pays 50% ^ Office Visits in Addition to Global Maternity Fee (Performed by OB/GYN or Specialist) Covered same as Physician Services - Office Visit Covered same as Physician Services - Office Visit Delivery - Facility (Inpatient Hospital, Birthing Center) Covered same as plan’s Inpatient Hospital benefit Covered same as plan’s Inpatient Hospital benefit Abortion Abortion Services Coverage varies based on Place of Service Coverage varies based on Place of Service Note: Elective and non-elective procedures Family Planning Women’s Services Plan pays 100% Coverage varies based on Place of Service Includes contraceptive devices as ordered or prescribed by a physician and surgical sterilization services, such as tubal ligation (excludes reversals) Men’s Services Coverage varies based on Place of Service Coverage varies based on Place of Service Includes surgical sterilization services, such as vasectomy (excludes reversals) Infertility Infertility Treatment Coverage varies based on Place of Service Coverage varies based on Place of Service Infertility covered services: lab and radiology test, counseling, surgical treatment, excludes artificial insemination and in-vitro fertilization, GIFT, ZIFT, etc.