External Prosthetic Appliances (EPA) After the plan deductible is met, your plan pays 80% After the plan deductible is met, your plan pays 60% Unlimited maximum per Contract Year Includes cranial banding, cranial orthoses and other similar devices based on medical necessity Routine Foot Disorders Not Covered Not Covered

Cigna benefit plans. Please note, the terms of acustomer’s particular benefit plan document [Group Service Agreement, and limitations of the applicable benefit plan’s External Prosthetic Appliances and Devices (EPA) or Durable Medical Equipment (DME) benefit and schedule of copayments. External Prosthetic Appliances (EPA) Your plan pays 100% Unlimited maximum per Calendar Year Routine Foot Disorders Not Covered Note: Services associated with foot care for diabetes and peripheral vascular disease are covered when medically necessary. Acupuncture Unlimited days maximum per Calendar Year $10 PCP or $20 Specialist copay External Prosthetic Appliances Includes ostomy supplies, cardiac pacemakers, braces, artificial limbs, orthotics, or other things that replace damaged, missing or non-working parts of the body. Follows Medicare standard guidelines. Maximum: Unlimited 80% after Part B deductible 8 0% 20% Diabetic Supplies and Services Your CIGNA HealthCare PPO plan Page 1 PPO 2006-AZ External Prosthetic Appliances $200 EPA deductible per calendar year $1,000 maximum per calendar year# 20% of charges* 50% of charges** Page 5 PPO 2006-AZ BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK Prescription Drugs External Prosthetic Appliances (EPA) After the plan deductible is met, your plan pays 80% After the plan deductible is met, your plan pays 60% Unlimited maximum per Contract Year Includes cranial banding, cranial orthoses and other similar devices based on medical necessity Routine Foot Disorders Not Covered Not Covered External Prosthetic Appliances Coverage is provided for the purchase and fitting of external prosthetic appliances which are used as a replacement or substitute for a missing body part and are necessary for the alleviation or correction of illness, - Cigna IRMP High Deductible Health Plan (HDHP) External prosthetic devices/surgical and medical appliances We will pay for: • a prosthetic device or appliance which is a necessary part of the treatment immediately following surgery for as long as is required by medical necessity. • a prosthetic device or appliance which is medically necessary and is part of the recuperation process on a External Prosthetic Appliances (EPA) Plan pays 80% ^ Annual Limit: Unlimited Temporomandibular Joint Disorder (TMJ) Unlimited Non-Surgical lifetime maximum Coverage varies based on Place of Service Note: Provided on a limited, case-by-case basis.

External prosthetic appliances cigna

Maximum: Unlimited 80% after Part B deductible 8 0% 20% Diabetic Supplies and Services Your CIGNA HealthCare PPO plan Page 1 PPO 2006-AZ External Prosthetic Appliances $200 EPA deductible per calendar year $1,000 maximum per calendar year# 20% of charges* 50% of charges** Page 5 PPO 2006-AZ BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK Prescription Drugs External Prosthetic Appliances (EPA) After the plan deductible is met, your plan pays 80% After the plan deductible is met, your plan pays 60% Unlimited maximum per Contract Year Includes cranial banding, cranial orthoses and other similar devices based on medical necessity Routine Foot Disorders Not Covered Not Covered External Prosthetic Appliances Coverage is provided for the purchase and fitting of external prosthetic appliances which are used as a replacement or substitute for a missing body part and are necessary for the alleviation or correction of illness, - Cigna IRMP High Deductible Health Plan (HDHP) External prosthetic devices/surgical and medical appliances We will pay for: • a prosthetic device or appliance which is a necessary part of the treatment immediately following surgery for as long as is required by medical necessity. • a prosthetic device or appliance which is medically necessary and is part of the recuperation process on a External Prosthetic Appliances (EPA) Plan pays 80% ^ Annual Limit: Unlimited Temporomandibular Joint Disorder (TMJ) Unlimited Non-Surgical lifetime maximum 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 Prosthetic Devices.

1 of 15 ©Cigna 2018 SUMMARY OF BENEFITS Cigna Health and Life Insurance Co. For - Proofpoint, Inc. Choice Fund Open Access Plus HSA Plan Selection of a Primary Care Provider - your plan may require or allow the designation of a primary care provider. You have the right to designate any primary care

Refer to the Orthotic and Prosthetic Appliances and Services section in the appropriate Part 2 manual for policy information. Number: 0403.

An external device (e.g., Spinal Stim) uses pulsating electromagnetic energy to induce weak electrical currents in the underlying tissue. The external electrical stimulation device consists of the magnetic coils incorporated into a corset like device which the patient wears 8 to 10 hours per day, usually while sleeping.

Fully covered 14. Pregnancy Complications Covers hospitalization and surgical costs associated with pregnancy An external device (e.g., Spinal Stim) uses pulsating electromagnetic energy to induce weak electrical currents in the underlying tissue.

There is no need to be dentally fit before joining and because the External Prosthetic Appliances No charge Family Planning Services Office Visits (Test, Counseling) Office Visit - $20 Copay Surgical Sterilization Procedure (Women) Surgical Sterilization Procedure (Men) Inpatient Hospital – No Charge Outpatient Facility – No charge Inpatient Hospital - $100 Copay per admission 09A2201310220000653805 Cigna HealthCare of Arizona, Inc. HMO This document takes the place of any documents previously issued to you which described your benefits. appliance [ah-pli´ans] any of various devices used in dentistry to provide a functional or therapeutic effect, such as a prosthesis, an obturator, or an orthodontic appliance EOC_ENG_Cigna_ 49375CO0060017_20170101 MIEP0165 1 Cigna Health and Life Insurance Company (“Cigna”) Cigna Connect Flex Silver 3500 - 200 Plan . SCHEDULE OF BENEFITS (WHO PAYS 2019-01-01 · In prosthetic applications, nanocomposites are used in orthopedic prosthetics, dental prosthetics, maxillofacial prosthetics, cardiac prosthetics, etc.
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With precertification, you find out in advance if a service is covered, which can help you lower costs and avoid unnecessary procedures. › External prosthetic appliances Proclaim - 8458148 - V 15 5 of 14 ©Cigna 2019 Benefit In-Network Out-of-Network 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 Your plan pays 100% After the plan deductible is met, your plan pays 70% External Prosthetic Appliances (EPA) Cigna care management helps you access the right care, at the right time, in the right setting. With precertification, – External prosthetic appliances – Speech therapy – Cosmetic or reconstructive procedures – Infertility treatment – Sleep management – Transplants External prosthetic devices/surgical and medical appliances Silver Health Gold Health Platinum Health; ฿65,000 (For each prosthetic device) ฿100,000 (For each prosthetic device) ฿100,000 (For each prosthetic device) Specialists' consultation fees Silver Health Gold Health Platinum Health; Paid in full. Paid in full. Paid in full Cigna HealthCare of Arizona, Inc. HMO This document takes the place of any documents previously issued to you which described your benefits.

Deductible, then 20% to the Out of Pocket Maximum DURABLE MEDICAL EQUIPMENT Deductible, then 20% to the Out of Pocket Maximum EXTERNAL PROSTHETIC APPLIANCES Deductible, then 20% to the Out of Pocket Maximum OTHER BENEFITS ORAL SURGERY (accidents only) REMOVAL OF BONEY IMPACTED WISDOM TEETH Cigna care management helps you access the right care, at the right time, in the right setting. With precertification, you find out in advance if a service is covered, which can help you lower costs and avoid unnecessary procedures. › External prosthetic appliances Proclaim - 8458148 - V 15 5 of 14 ©Cigna 2019 Benefit In-Network Out-of-Network 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 Your plan pays 100% After the plan deductible is met, your plan pays 70% External Prosthetic Appliances (EPA) Cigna care management helps you access the right care, at the right time, in the right setting. With precertification, – External prosthetic appliances – Speech therapy – Cosmetic or reconstructive procedures – Infertility treatment – Sleep management – Transplants External prosthetic devices/surgical and medical appliances Silver Health Gold Health Platinum Health; ฿65,000 (For each prosthetic device) ฿100,000 (For each prosthetic device) ฿100,000 (For each prosthetic device) Specialists' consultation fees Silver Health Gold Health Platinum Health; Paid in full.
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External prosthetic devices/surgical and medical appliances We will pay for: • a prosthetic device or appliance which is a necessary part of the treatment immediately following surgery for as long as is required by medical necessity. • a prosthetic device or appliance which is medically necessary and is part of the recuperation process on a

Please note, the terms of acustomer’s particular benefit plan document [Group Service Agreement, and limitations of the applicable benefit plan’s External Prosthetic Appliances and Devices (EPA) or Durable Medical Equipment (DME) benefit and schedule of copayments. External Prosthetic Appliances (EPA) Your plan pays 100% Unlimited maximum per Calendar Year Routine Foot Disorders Not Covered Note: Services associated with foot care for diabetes and peripheral vascular disease are covered when medically necessary.

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Internal prosthetic devices/surgical and medical appliances: Paid in full. External prosthetic devices/surgical and medical appliances: “Cigna®" is a

PRESCRIPTION DRUG Coverage for replacement of external prosthetic appliances and devices is Cigna Health and Life Insurance Co. For - Sunrun Cigna may designate one for you until you make this designation. External Prosthetic Appliances (EPA).