01/01/2026 ASO Open Access Plus - OAP Traditional Plan Proclaim - 37302332 - V 33 - 10/20/25 05:18 PM ET 6 of 18 ©Cigna 2025 Benefit In-Network Out-of-Network Note: Services where plan deductible applies are noted with a caret (^). Benefit copays/deductibles always apply before plan deductible. 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. Outpatient Dialysis Services Physician’s Services/Office Visit Covered same as Physician Services - Office Visit Not Covered Home Dialysis Note: Dialysis visits will not accumulate to Home Health Care maximum Covered same as plan's Home Health Care benefit Not Covered Outpatient Facility Services Covered same as plan's Outpatient Facility Services benefit Not Covered Outpatient Professional Services Covered same as plan’s Outpatient Professional Services benefit Not Covered