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CIGNA GLOABAL SHORT TERM ABROAD
(STA) PLAN
79
Employee Pays
INTERNATIONAL COVERAGE ONLY
Services received in home country or the United States are not covered
Deductible
Individual
Family – No Coverage
$250 per calendar year
None
Maximum Out of Pocket
Individual
Family – No Coverage
$1,000
None
Lifetime Maximum
Unlimited
Office Visit
20% After Deductible
Specialist
20% After Deductible
Preventive Care
Wellness Care
Routine Physical Exams
Gynecological Exams
PSA & DRE
Mammograms
100% Covered
Emergency Health Services
20% After Deductible
Ambulance Services
20% After Deductible
Urgent Care
20% After Deductible
Hospital
Inpatient
Outpatient
20% After Deductible
20% After Deductible
Maternity
20% After Deductible
Mental Health
Inpatient
Outpatient
20% After Deductible
20% After Deductible
Emergency Medical Evacuation
100% Covered – Not subject to deductible
Prescription Drugs
20% After Deductible