Coinsurance Paid by the Expatriate Medical Plan
Whenever benefits are limited to a certain dollar amount or number of visits/days, care received in-network, out-of-network, and outside the United States will be combined and counted toward the annual deductible.
The following tables show the coinsurance percentage paid by the Expatriate Medical Plan for covered expenses.
Out-of-network expenses incurred in the U.S. or outside the U.S. are subject to reasonable and customary (R&C) limits; you are responsible for 100% of all charges above those R&C amounts. Amounts that you pay above R&C limits do not count toward your deductible or coinsurance maximum. Because in-network charges for covered services have been negotiated with the providers, those charges would always be within the R&C limits.
Eligible Preventive Care
Please Note: A medical service will only be covered at 100% if it is coded as
preventive. Before receiving any service, you should check with your physician to be sure the procedure is considered, and will be submitted to the claims administrator, as preventive medical care rather than as a diagnostic service. Cigna determines the eligible preventive care services covered at 100%. See "
SPD Box Regular EndMarkerPreventive Care Services
Preventive Care Services" for more information about eligible preventive care services.
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Care Received Inside the United States
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Care Received Outside the United States
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Provision
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In-Network
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Out-of-Network
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Routine Physical Exams at the following frequency:
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From birth to 12 months: seven exams
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Age 13 – 24 months: three exams
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Age 2 and over: one exam every year
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60% after deductible
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100%
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Routine Immunizations
(adult and child; including immunizations related to travel)
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100%
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60% after deductible
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100%
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Routine Mammograms (annually age 40 and up)
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100%
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60% after deductible
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100%
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Routine Gynecological Exams and Pap Smears, including related laboratory fees (annually; age guidelines apply)
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100%
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60% after deductible
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100%
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Routine Prostate Specific Antigen (PSA) Test (annually age 40 and up)
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100%
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60% after deductible
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100%
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Routine Digital Rectal Exam (annually age 40 and up)
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100%
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60% after deductible
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100%
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Routine Fecal Occult Blood Test (annually age 50 and up)
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100%
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60% after deductible
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100%
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Routine Sigmoidoscopy /Colonoscopy (baseline screening beginning at age 50; follow-up screening every five years)
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100%
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60% after deductible
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100%
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Routine Eye Exams (maximum one exam per year)
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100%
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60% after deductible
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100%
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Routine Hearing Exams (maximum one exam every 2 years)
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100%
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60% after deductible
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100%
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Outpatient Services
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Care Received Inside the United States
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Care Received Outside the United States
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Provision
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In-Network
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Out-of-Network
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Doctor's Office Visits (to family practitioners, internists, pediatricians, and OB/GYNs, and consultations, specialist visits, convenience care clinic visits and second surgical opinions; also includes tests, injection drugs, supplies, and other services authorized by the Plan and provided during the visit and billed by the physician)
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80% after deductible
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60% after deductible
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80% after deductible
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X-rays and Labs (when performed to diagnose a medical problem or treat an illness or injury)
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80% after deductible
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60% after deductible
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80% after deductible
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Surgery/Major Medical
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80% after deductible
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60% after deductible
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80% after deductible
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Infertility Services (includes diagnostic procedures, in vitro fertilization, artificial insemination, etc.; limited to combined in-/out-of-network/outside the U.S. maximum of $20,000 lifetime for each covered employee and/or spouse/domestic partner*)
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80% after deductible
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60% after deductible
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80% after deductible
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Speech, Physical, or Occupational Therapy — outpatient (combined in-/out-of-network/ outside U.S. limit of 60 visits/calendar year per therapy type*)
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80% after deductible
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60% after deductible
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80% after deductible
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Spinal Treatment/
Chiropractic Care (coverage ends when medical recovery is achieved and treatment is for maintenance or managing pain; limited to 20 visits/calendar year*)
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80% after deductible
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60% after deductible
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80% after deductible
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Mental Health Care
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80% after deductible
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60% after deductible
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80% after deductible
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Substance Abuse Care
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80% after deductible
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60% after deductible
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80% after deductible
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* Combined in-/out-of-network and outside U.S. All out-of-network expenses are subject to reasonable and customary (R&C) charges. You are responsible for paying any charges above the R&C amount. Since in-network charges for covered services have been negotiated with the providers, those charges would always be within the R&C limits.
Inpatient Services
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Care Received Inside the United States
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Care Received Outside the United States
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Provision
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In-Network
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Out-of-Network
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Hospital (based on hospital's standard rate for semi-private or common rooms, except for isolation of communicable diseases; excluding emergency room care)
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100% after $250 copayment per admission; waived if readmitted for same condition within 14 days
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60% after deductible per admission
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100% after $250 copayment per admission; waived if readmitted for same condition within 14 days
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Surgery/Major Medical
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80% after deductible
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60% after deductible
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80% after deductible
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Skilled Nursing Facility (must be ordered by physician as medically necessary; limited to combined in-/out-of-network/outside U.S. maximum of 365 days per lifetime for each covered individual)
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100% after $250 copayment; waived if admitted from hospital
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60% after deductible
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100% after $250 copayment; waived if admitted from hospital
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Hospice Care
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100% after $250 copayment; waived if admitted from hospital
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60% after deductible
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100% after $250 copayment; waived if admitted from hospital
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Mental Health Care
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100% after $250 copayment per admission
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60% after deductible
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100% after $250 copayment per admission
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Substance Abuse Care
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100% after $250 copayment per admission
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60% after deductible
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100% after $250 copayment per admission
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Home Health Care (medically necessary only; limited to combined in-/out-of-network/outside U.S. maximum of 200 visits/calendar year; one visit = four hours)
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80% after deductible
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60% after deductible
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80% after deductible
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Durable medical equipment
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80% after deductible
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60% after deductible
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80% after deductible
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Prosthetics
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Covered 100%
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60% after deductible
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Covered 100%
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Prescription Drugs
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Care Received Inside the United States
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Care Received Outside the United States
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Provision
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In-Network
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Out-of-Network
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Prescription drugs ($10,000 lifetime maximum for infertility drugs; exclusive of treatment)
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75% (deductible waived)
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75% (deductible waived)
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75% (deductible waived)
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Other Services
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Care Received Inside the United States
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Care Received Outside the United States
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Provision
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In-Network
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Out-of-Network
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Hospital — emergency room
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100% after $150 copayment per visit; must be sudden and serious; waived if admitted.
80% coverage after deductible if not considered an emergency
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100% after $150 copayment per visit; must be sudden and serious; waived if admitted
60% coverage after deductible if not considered an emergency
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100% after $150 copayment per visit; must be sudden and serious; waived if admitted
80% coverage after deductible if not considered an emergency
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