01/01/2026 ASO Open Access Plus - OAP Traditional Plan Proclaim - 37302332 - V 33 - 10/20/25 05:18 PM ET 7 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. Other Health Care Facilities/Services Home Health Care Plan pays 80% ^ Plan pays 50% ^  Annual Limit: 60 days (The limit is not applicable to mental health and substance use disorder conditions.)  16 hour maximum per day Note: Includes outpatient private duty nursing when approved as medically necessary Organ Transplants Inpatient Hospital Facility Services LifeSOURCE Transplant Network® facility Plan pays 100% Not Applicable Other Facility Not Covered Not Covered Inpatient Professional Services LifeSOURCE Transplant Network® facility Plan pays 100% Not Applicable Other Facility Not Covered Not Covered  Travel Maximum - Cigna LifeSOURCE Transplant Network® facility only: $10,000 maximum per Transplant Durable Medical Equipment  Annual Limit: Unlimited Plan pays 80% ^ Plan pays 50% ^ Breast Feeding Equipment and Supplies  Limited to the rental of one breast pump per birth as ordered or prescribed by a physician  Includes related supplies Plan pays 100% Plan pays 50% ^