01/01/2026 ASO Open Access Plus - OAP Traditional Plan Proclaim - 37302332 - V 33 - 10/20/25 05:18 PM ET 8 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. External Prosthetic Appliances (EPA) Plan pays 80% ^ Plan pays 50% ^  Annual Limit: Unlimited Temporomandibular Joint Disorder (TMJ)  Unlimited Non-Surgical lifetime maximum Coverage varies based on Place of Service Coverage varies based on Place of Service Note: Provided on a limited, case-by-case basis. Excludes appliances and orthodontic treatment. Routine Foot Care Not Covered Not Covered Note: Services associated with foot care for diabetes and peripheral vascular disease are covered when approved as medically necessary. Hearing Aids Plan pays 80% ^ Plan pays 50% ^  $2,500 maximum per Calendar Year  Includes testing and fitting of hearing aid devices at Physician Office Visit cost share Wigs  Maximum of 1 wig per Lifetime Plan pays 80% ^ Plan pays 80% ^ Travel Services  Authorized eligible travel and lodging expenses when an In- network facility/provider is not available within a 60 mile radius from your primary home residence  Coverage for designated services only including all Medical and Outpatient Mental Health and Substance Use Disorder Services  Coverage when travelling to an in-network provider/facility only  Medical Lifetime Maximum: $10,000  Behavioral Lifetime Maximum: Unlimited Plan pays 100% Not Covered