Microsoft word - bsf79543.doc

Your Preferred In-Network
Out-of-Network
Provider Access Plan CHOICE OF DOCTORS
OUT-OF-NETWORK COVERAGE
You can use any “preferred provider” in You’re still covered when you go out of our network without a referral. Or, when network, though your cost will be higher. (PPA) provides you wish, you can go out of network. convenient, When you receive care from a preferred deductible. See the out-of-network costs low-cost coverage in providers in your “CIGNA HealthCare DEDUCTIBLES AND OUT-OF-
POCKET MAXIMUMS
PERSONALIZED CARE
Your plan deductibles do not apply to the In the private office of your physician. HOSPITALIZATION
pays 100% of eligible charges for the rest of the plan year, except for Mental Health of network when hospital in our network and your stay has and Substance Abuse which continue to CIGNA'S TOLL-FREE CARE LINE
Call for steps to take before admittance to THESE ARE ONLY THE
a hospital, or for assistance in finding a HIGHLIGHTS
If you have any questions about a specific or out of town. Call CIGNA customer service or treatment, contact Customer service at the toll-free number indicated on your ID Card for further information. EMERGENCY CARE
No matter where you travel in the U.S. or worldwide, you’re covered for emergency PPA – Copay Plan
care. See your “CIGNA HealthCare
NO CLAIMS OR
OTHER PAPERWORK
For Employees of
LEGAL SERVICES FOR
NEW YORK CITY
AT A GLANCE
IN-NETWORK
OUT-OF-NETWORK
Annual Deductible
Annual Out-of-Pocket Maximum
Pre-existing Condition Limitation
Lifetime Maximum
Preadmission Certification/
Continued Stay Review
Call the toll free number indicated on ID Card. Call the toll free number indicated on ID Card. SPECIFIC BENEFITS
IN-NETWORK
OUT-OF-NETWORK
Office Visit
Routine Preventive Care for Dependent Children including Immunizations birth thru age 18 Routine Preventive Care for Adults (incl. Well Adult Exams (including pap test, PSA, etc.) $20 per visit, or actual charge whichever is less NOTE: New York residents only: No charge
In-Network
Routine Mammograms
$20 per office visit copay for associated well woman exam; No charge for separate outpatient facility Prescription Drugs (includes oral contraceptives, diabetic drugs & supplies, prenatal prescription vitamins)
Generic - 30-day supply
Tel-Drug Mail Order Plan
Maternity Care
$20 for first visit to confirm pregnancy, then includes subsequent prenatal/postnatal visits Family Planning
Office Visit incl. tests & counseling Vasectomy/Tubal Ligation (excludes reversals)
Infertility Services
Office Visit (includes tests & counseling) Surgery (excludes in-vitro fertilization, artificial
SPECIFIC BENEFITS
IN-NETWORK
OUT-OF-NETWORK
Emergency Care
Care will be covered at in-network benefit level if it Hospital Emergency Room/Urgent Care Facility meets CIGNA HealthCare's definition of emergency Outpatient Preadmission Testing
Office Visit- Primary Care Physician/Specialist Inpatient Hospital Care
Facility charges (Limited to semi-private room rate) Surgeon's Fees
Outpatient Surgical Facility
Outpatient Short-Term Rehabilitation
incl. Physical, Speech & Occupational Therapy
Chiropractic Therapy
Second Surgical Opinion
X-ray and Lab
Special Services
Mental Health Services
Substance Abuse Treatment

* Subject to calendar year deductible and reasonable and customary charge limitations for out-of-network services. ** Treatment maximums cross-accumulate.
All deductibles and plan out-of-pocket maximums accumulate in one direction toward in-network unless otherwise noted.

Regarding In-Network and Out-of-Network services:
Once the out-of-pocket maximum is reached, the plan pays 100% of eligible charges for the remainder of the plan year, except for Mental Health and Substance Abuse which continue to be paid at the levels specified. All inpatient hospital admissions require Preadmission Certification and Continued Stay Review. To pre-certify, call the toll free number indicated on your ID card. Regarding In-Network services: All services must be provided by one of the preferred providers on our list. Regarding Out-of-Network services: Your out-of-pocket costs will be higher than with a preferred provider. BEHAVIORAL HEALTH
Mental Health and Substance Abuse Services are provided by CIGNA Behavioral Health, such expenses are incurred for: a) charges access care, call 24 hours a day, 7 days a week treatment started within six months of an at the toll free number listed on your ID Card. Custodial services not intended primarily injury to sound, natural teeth; b) charges to treat a specific injury or sickness, or CASE MANAGEMENT
Coordinated by CIGNA HealthCare. This is a service designed to provide assistance to a hospitalizations not required for health patient who is at risk of developing medical complexities or for whom a health incident has precipitated a need for rehabilitation or additional health care support. The program Charges for or in connection with in vitro IMPORTANT NOTE
strives to attain a balance between quality and fertilization, artificial insemination, or This summary contains highlights only and is cost effective care while maximizing the subject to change. The specific terms of Transsexual surgery and related services. coverage, exclusions, and limitations, including legislated benefits, are contained in EXCLUSIONS
the Plan Description or insurance certificate. Your plan provides coverage for medically This Plan is insured and/or administrated by Connecticut General Life Insurance Company, provide coverage for the following except as Services that are not medically necessary, determination of a fetus, unless medically necessary to determine the existence of a receives an injury which results in bodily pills, minoxidil or Retin-A after age 35, necessary; c) it qualifies as reconstructive the other breast to achieve symmetry; or d) it is performed to correct a congenital developed; b) can be considered custodial or educational; or c) intended to maintain which is not restorative in nature, will not charges are directly related to a sickness or injury connected to military service. lenses with the exception of the first pair Catalog Number: BSF79543 (09/04)
PPA Copay
“CIGNA HealthCare” refers to various operating subsidiaries of CIGNA Corporation. Products and services are provided by these subsidiaries and not by CIGNA Corporation. These subsidiaries include Connecticut General Life Insurance Company., Tel-Drug, Inc. and its affiliates, CIGNA Behavioral Health, Inc., Intracorp, and HMO or service company subsidiaries of CIGNA Health Corporation and CIGNA Dental Health, Inc.

Source: http://lssa2320.org/wp-content/uploads/2013/10/Cigna-SOB.pdf