Other Covered Services

Compression stockings (two pair per calendar year for the following conditions only: diabetes, varicose veins, varicose ulcers, stasis dermatitis, post-phlebitic syndrome, and lymphedema);
Dental procedures resulting from a congenital disorder or medical disorder or accidental injury (treatment must be received within 12 months of the accident). Includes surgical removal of wisdom teeth only if procedure is done in medical setting. Please Note: The charges must not be covered by the Expatriate Dental Plan;
Gender Reassignment Surgery (GRS) — in order to be eligible, the participant must meet certain medically established guidelines for obtaining the surgery (Harry Benjamin guidelines) which require the participant to, among other things:
Be at least 18 years old;
Have a GID (Gender Identity Disorder) diagnosis;
Have been approved for hormone therapy;
Have at least one year's real life experience living and working in desired gender; and
Have two letters endorsing surgery, including one from a mental health provider at the doctorate level.
Follow-up procedures such as electrolysis, breast augmentation surgery, and facial surgery will not be covered.
Surgery must be preauthorized by the medical plan administrator whether in or out-of-network or outside the United States.
Hearing aid evaluations and hearing tests;
Hearing aids up to $3,000 every 36 months;
Home health care approved by Cigna Global Health Benefits. The attending physician must submit a detailed description of the medical necessity and scope of services to Cigna Global Health Benefits. The following are covered if ordered by the physician under the home health care plan and provided in the patient's home. (Please check with Cigna Global Health Benefits for any age or frequency limitations.):
Part-time or intermittent nursing care provided or supervised by a registered nurse (R.N.);
Part-time or intermittent home health services, primarily for the patient's medical care;
Physical, occupational, speech, or respiratory therapy by a licensed qualified therapist;
Nutrition counseling provided by or under the supervision of a registered dietitian; and
Medical supplies, laboratory services, drugs, and medications prescribed by a physician.
Intensive behavior therapy, such as Applied Behavior Analysis (ABA) for Autism Spectrum Disorder, subject to precertification from Cigna Global Health Benefits;
Local ambulance service or air ambulance to the nearest hospital if medically necessary and confirmed by a licensed provider;
Medical equipment and supplies including blood and blood plasma (unless donated on behalf of the patient); artificial limbs (excluding replacements), artificial eyes and larynx (including fitting); heart pacemaker; surgical dressings; casts; splints; trusses; orthopedic braces; crutches; wheelchair; walker; cane; insulin pump; Athner monitor; custom-molded shoe inserts prescribed to treat a condition, disease or illness affecting the function of the foot; hospital bed; ventilator; iron lung; ostomy supplies, including pouches, face plates and belts, irrigation sleeves, bags and ostomy irrigation catheters; and other items necessary to the treatment of an illness or injury that are not excluded under the Plan. Prior authorization or precertification may be required for coverage of some medical equipment and supplies. Cigna Global Health Benefits may authorize purchase of an item if more cost-effective than rental.
Medically necessary visits to licensed physicians, surgeons, and chiropractors, whether in the office or in your home;
Nutritional support, including nutritional counseling (limited to three visits for diabetes and three visits for non-diabetes counseling, for a total of six visits) and durable medical equipment to treat inborn errors of metabolism and/or to function as the majority source of nutrition*, as long as each of the following conditions are met:
Without enteral (feeding tube) feedings, the individual is unable to obtain sufficient nutrients to maintain appropriate weight by dietary and/or oral supplements;
The administration of enteral nutrition requires ongoing evaluation and management by a physician; and
The individual has one of the following conditions that is expected to be permanent or of indefinite duration:
An anatomical or motility disorder of the gastrointestinal tract that prevents food from reaching the small bowel;
Disease of the small bowel that impairs absorption of an oral diet; or
A central nervous system/neuromuscular condition that significantly impairs the ability to safely ingest oral nutrition

Enteral feeding constitutes over 50% of caloric nutritional intake as determined by clinical information submitted by the provider for review;
Calories from parenteral (intravenous) nutrition should not be considered when assessing for the sole source of nutrition; i.e., transitioning to enteral feedings; and
Parenteral feedings are covered when considered "medically necessary" and used when oral or enteral alone are not possible.
Oxygen and supplies for its administration;
Prosthetic devices and supplies, including fitting, adjustments, and repairs, if ordered by a licensed provider. Please check with Cigna Global Health Benefits for frequency or other limitations. (Please Note: Dentures, bridges, etc., are not considered medical prosthetic devices.);
Radiation, chemotherapy, and kidney dialysis;
Rental or purchase of durable medical equipment as determined by Cigna Global Health Benefits, if ordered by a licensed provider. Please check with Cigna Global Health Benefits for frequency or other limitations;
Services and supplies that are part of an alternate care proposal. This is a course of treatment developed and authorized by Cigna Global Health Benefits as an alternative to the services and supplies that would otherwise have been considered covered services and supplies. Unless specified otherwise, the provisions of the Plan related to benefit amounts, maximum amounts, copayments, and deductible will apply to these services;
Skilled nursing facility for up to 365 days per lifetime (combined in-/out-of-network care and care received outside the United States) under the Expatriate Medical Plan and for up to 120 days per lifetime combined in-network and out-of-network under the Medicare Indemnity Plans. The lifetime maximums reflect services received across the Expatriate Medical Plan, the Consumer Driven Health Plans (Option 1 and Option 2), and under prior medical plans of JPMorgan Chase (such as the Point Service High/Low and the Consumer Driven Health Plan) and the medical plans of a heritage organization that was acquired by JPMorgan Chase;
Urgent care;
Voluntary sterilization; and
Wigs up to a $500 per year limit, for burns, chemotherapy or radiation, accidental injury, following a diagnosis of Alopecia, or for other medically necessary reasons.