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Medical Plan Summaries
Medical Plan Summaries for CIGNA Open Access and CIGNA Point of Service (POS) are provided below. Employees and retirees can choose between these two medical plans. Note that the most recent updates to the Vision Plan benefits are now included in the Medical Plan Summaries available here.
Click a link below to reveal summary information on that medical plans. Click again to close. To see summaries of both medical plans, click here. To print this page, first click the link to one or both plans; then use your browser print command (File/Print or Control-P).
Summary Information on CIGNA Open Access and CIGNA POS for 2009 (through December 31, 2009)
| Services Covered | In-Network | Out-of-Network |
|---|---|---|
| Annual Deductible Amount for injury, illness, or maternity | $300/individual $600/family |
$500/individual $1,000/family |
| Out-of-Pocket Annual Limit (excludes deductible) | $1500/individual $3000/family |
$4500/individual $9000/family |
| Pre-Existing Conditions | N/A | N/A |
| Maximum Lifetime Benefit | $2,000,000 (combined in- and out-of-network maximum) | $2,000,000 (combined in- and out-of-network maximum) |
| Physician Care | ||
|---|---|---|
| Primary Care Office Visit | Covered 100% after $15 copay | Covered 60% of R&C* after deductible |
| Specialist Office Visit | Covered 100% after $30 copay | Covered 60% of R&C* after deductible |
| Physician and Surgeon Services in Hospital | Covered 90% after plan deductible | Covered 60% of R&C* after deductible |
| Maternity Office Visits | Covered 100% after one-time physician's office visit copay | Covered 60% of R&C* after deductible |
| Maternity Delivery (Physician charges) | Covered 90% after plan deductible | Covered 60% of R&C* after deductible |
| Preventive Health Services | ||
| Covered 100% after: | ||
| Well Baby Care | $15 copay (including immunizations) | Not covered |
| Routine Physical Exams | $15 primary care office copay | Not covered |
| Routine Gynecological Exams | $30 physician's office copay, if physician used is contracted as specialist $15 physician's office copay, if physician used is contracted as primary care physician |
Not covered |
| Routine Mammogram | No charge (no referral needed) | Covered 60% of R&C* after deductible |
| Hearing Aid Benefits | $750 maximum every 36 months | Not covered |
| Outpatient Laboratory and X-ray (all charges billed by an independent facility) | Covered 100% | Covered 60% of R&C* after deductible |
| Home Health Care (skilled visits only) | Covered 100% | Covered 60% of R&C* after deductible for up to 60 days per calendar year, reduced by any in-network visits |
| Chiropractic Care (when medically appropriate) | Covered 100% after $30 copay; 25-visit limit per year | Not covered |
| Substance Abuse (outpatient) | $30 copay per visit for individual therapy
$15 copay per visit for group therapy |
Covered 60% of R&C* after deductible; up to 35-visits limit per year reduced by any in-network visits |
| Mental Health Service (outpatient) | $30 copay per visit for individual therapy
$15 copay per visit for group therapy |
Covered 60% of R&C* after deductible; up to 35-visits limit per year reduced by any in-network visits |
| Physician Services in Emergency Room | Covered 100% | Covered 100% |
| Durable Medical Equipment | Covered 100% | Covered 60% of R&C* after deductible |
| Infertility Treatment | ||
| 60% of R&C* after plan deductible | ||
| Physician office visit, test, counseling | $30 copay per office visit, then covered 100% | |
| Surgical treatment— includes procedures for correction of infertility (invitro fertilization, artificial insemination, GIFT, ZIFT, etc.) | Inpatient and outpatient facility same as inpatient and outpatient hospital. Physician services 90% after plan deductible | |
| Limited coverage; lifetime maximum $20,000 | ||
| External Prosthetic Devices — Requires approval by Healthplan (see note) | Covered 90% after deductible and $100 copay | Covered 60% of R&C* after deductible |
| Note: Coverage for external prosthetic appliances and devices is limited to the most appropriate and cost-effective alternative as determined by the utilization review physician. Covers initial purchase and fitting of any physician-ordered or -prescribed external prosthetic devices that are to be used as replacements or subsitutes for missing body parts and are necessary for the alleviation or correction of sickness, injury, or congenital defects. | ||
| Hospital Care | ||
| Inpatient Services |
||
| Semi-private room, operating room, X-ray, and laboratory services | Covered 90% after deductible and $250 copay per admission | Covered 60% of R&C* after deductible and $500 copay per admission |
| Includes stand-alone facilities such as Birthing Center | ||
| Outpatient Services | ||
| Operating Room, Recovery Room, Procedure Room, and Treatment | Covered 90% after deductible and $150 copay per visit | Covered 60% of R&C* after deductible and $300 copay per visit |
| Organ Transplant Coverage | ||
| Inpatient Facility | Covered 90% after deductible and $250 copay at approved facilities | Covered 60% of R&C* after deductible |
| Travel Benefit | $10,000 per transplant per lifetime available when using an approved facility | Not covered |
| Emergency Room Services | Covered 100% after $100 copay per visit if true emergency (waived if admitted) | Covered 100% after $100 copay per visit if true emergency (waived if admitted) |
| Ambulance Services | Covered 100% if true emergency; otherwise, not covered | Covered 100% if true emergency; otherwise, not covered |
| Urgent Care Facility | Covered 100% after $50 copay per visit | Covered 100% after $50 copay per visit |
| Inpatient Mental Health | Covered 90% after deductible and $250 copay per admission; 20 days per calendar year in- and out-of-network combined | Covered 60% of R&C* after deductible; 20 days per calendar year in- and out-of-network combined |
| Inpatient Substance Abuse | Covered 90% after deductible and $250 copay per admission. Limited to 2 admissions per lifetime and 100 days per lifetime in- and out-of-network combined. |
Covered 60% of R&C* after deductible. Limited to 2 admissions per lifetime and 100 days per lifetime in- and out-of-network combined |
| Maternity — Inpatient | Covered 90% after deductible and $250 copay for mother (includes child) | Covered 60% of R&C* after deductible |
| Skilled Nursing Facility | Covered 90% after deductible for up to 60 days per calendar year in- and out-of-network combined | Covered 60% of R&C* after deductible for up to 60 days per calendar year in- and out-of-network combined |
| Hospice Care | ||
| Inpatient | Same as inpatient hospital | Covered 60% of R&C* after deductible |
| Outpatient | Covered 100%, no copay | Covered 60% of R&C* after deductible |
| Outpatient (short-term) rehabilitation Includes speech, occupational, physical, and cardiac rehabilitation |
Covered 100%. 180 days per year for all conditions for in- and out-of-network combined | Covered 60% of R&C* after deductible. 180 days per year for all conditions for in- and out-of-network combined |
*R&C = Reasonable and customary charges in your geographic area for similar services.
Please note:
Please note:
- In-network copays will not apply toward the out-of-network annual deductibles.
- All out-of-network inpatient hospitalizations and outpatient surgeries must be precertified. Failure to do so will result in denied claims.
- Hospital stays not deemed medically necessary will be disapproved.
- This plan does not cover bariatric surgery (gastric bypass) and non-cancerous skin tag removal.
- This plan will cover rhinoplasty, breast reductions, varicose veins and blepharoplasty surgery (removal of excessive eyelid tissue) if medically necessary. Prior health plan approval is required. This plan change is effective Jan. 1, 2008.
| Prescription Drugs** | ||
|---|---|---|
| Services Covered | In-Network | Out-of-Network |
| Retail Prescription Drugs — up to 30-day supply | $150 deductible Generic: 20% (minimum $10 copay) after deductible Brand: 30% (minimum $10 copay) after deductible If actual cost is under $10, then you pay actual cost |
50% of cost after $150 deductible |
| Mail Order — Home Delivery | Generic: $15 copay for up to a 90-day supply Brand: $35 copay for up to a 90-day supply |
Not covered |
**All pharmacy benefits for the CIGNA Open Access plan are through Medco.
Certain drugs may require a prior authorization in order to receive the prescription or the full quantity your doctor prescribes. For a listing of the brand names or categories that currently require prior authorization, you may refer to the Benefits Homepage or contact Medco at 1.800.685.8869.
Certain drugs may require a prior authorization in order to receive the prescription or the full quantity your doctor prescribes. For a listing of the brand names or categories that currently require prior authorization, you may refer to the Benefits Homepage or contact Medco at 1.800.685.8869.
| Vision Plan** | ||
|---|---|---|
| Services Covered | In-Network | Out-of-Network |
| Exam every 12 months | Covered in full | Exam – $29.75 |
| Lenses every 12 months Single vision Bifocal Trifocal Polycarbonate for dependent children |
Covered in full Covered in full Covered in full Covered in full |
Single Vision – $21.25 Bifocals – $34.00 Trifocal – $46.75 |
| Frames every 24 months | Covered up to $120 Plus, 20% off amount exceeding $120 |
Frames – $38.25 |
| — Or — | ||
| Contact Lens every 12 months | Covered up to $120, allowance applies to the cost of contacts and contact lens exam Plus, 15% off cost of contact lens exam — Or — Eligible members may take advantage of VSP Contact Lense Care Program, in which contact lens exam and up to 4 boxes (6 month supply) are covered in full |
Elective Contacts – $105 |
| Lens Options | 20% discount on lens enhancements and upgrades | |
| Additional Discounts | ||
| Additional prescription glasses and sunglasses | 20% discount | |
| Laser vision correction services | Provided at a reduced cost through VSP network doctors and contracted laser surgery centers | |
**Vision benefits for the CIGNA Open Access plan are through VSP.
Note: Every attempt has been made to ensure the accuracy of this summary. However, its contents are not legally binding nor should it be considered as a substitute for the actual contract language, company policies, or Your Book of Benefits.
| Services Covered | In-Network | Out-of-Network |
|---|---|---|
| Annual Deductible Amount for injury, illness, or maternity | None | $200/individual $400/family |
| Out-of-Pocket Annual Limit (excludes deductible) | $1000/individual $2000/family |
$3000/individual $6000/family |
| Pre-Existing Conditions | N/A | N/A |
| Maximum Lifetime Benefit | Unlimited | $2,000,000 (in- and out-of-network combined) |
| Physician Care | ||
|---|---|---|
| Primary Care Office Visit, Specialist Office Visit | Covered 100% after $10 copay | Covered 80% of R&C* after deductible |
| Physician and Surgeon Services in Hospital | Covered 100% | Covered 80% of R&C* after deductible |
| Maternity Office Visits | Covered 100% after one-time physician's office visit copay | Covered 80% of R&C* after deductible |
| Maternity Delivery (Physician charges) | Covered 100% | Covered 80% of R&C* after deductible |
| Preventive Health Services | ||
| Covered 100% after: | ||
| Well Baby Care | $10 copay (including immunizations) | Not covered |
| Routine Physical Exams | $10 copay | Not covered |
| Routine Gynecological Exams | $10 copay | Not covered |
| Routine Mammogram | No charge (no referral needed) | Covered 80% of R&C* after deductible |
| Hearing Aid Benefits | Not covered | Not covered |
| Outpatient Laboratory and X-ray (all charges billed by an independent facility) | Covered 100% | Covered 80% of R&C* after deductible |
| Home Health Care (skilled visits only) | Covered 100%; up to 60 days per calendar year, in- and out-of-network combined | Covered 80% of R&C* after deductible for up to 60 days per calendar year, in- and out-of-network combined |
| Chiropractic Care (when medically appropriate), no referral required | Covered 100% after $10 copay per visit; 25-visit limit per year | Not covered |
| Substance Abuse (outpatient) | $10 copay per visit for individual therapy
$10 copay per visit for group therapy 35 visit limit per calendar year in-and out-of-network combined |
Covered 80% of R&C* after deductible; 35-visit limit per calendar year in- and out-of-network combined |
| Mental Health Service (outpatient) | Covered 100% after $10 copay per visit; 35-visit limit per calendar year, in- and out-of-network combined | Covered 80% of R&C* after deductible; 35-visit limit per calendar year in- and out-of-network combined |
| Physician Services in Emergency Room | Covered 100% | Covered 100% |
| Durable Medical Equipment | Covered 100%, maximum of $3500 per calendar year | Not covered |
| Infertility Treatment | ||
|
[Physician office visit, test, counseling Surgical treatment — includes procedures for correction of infertility (invitro fertilization, artificial insemination, GIFT, ZIFT, etc.)] |
Not covered | Not covered |
| External Prosthetic Devices — Requires approval by Healthplan (see note) | Covered 100% after $200 deductible; maximum of $1000 per calendar year | Not covered |
| Note: Coverage for external prosthetic appliances and devices is limited to the most appropriate and cost-effective alternative as determined by the utilization review physician. Covers initial purchase and fitting of any physician-ordered or -prescribed external prosthetic devices that are to be used as replacements or subsitutes for missing body parts and are necessary for the alleviation or correction of sickness, injury, or congenital defects. | ||
| Hospital Care | ||
| Inpatient Services | ||
| Semi-private room, operating room, x-ray, and laboratory services; includes stand-alone facilities such as Birthing Center | Covered 100%, no copay | Covered 80% of R&C* after deductible |
| Outpatient Services | ||
| Operating room, recovery room, procedure room, and treatment | Covered 100% | Covered 80% of R&C* after deductible |
| Organ Transplant Coverage | ||
| Inpatient Facility | Covered 100% at approved facilities | Not covered |
| Travel Benefit | $10,000 per transplant per lifetime available when using an approved facility | Not covered |
| Emergency Room Services | Covered 100% after $50 copay per visit if true emergency (waived if admitted) | Covered 100% after $50 copay per visit if true emergency (waived if admitted) |
| Ambulance Services | Covered 100% if true emergency; otherwise, not covered | Covered 100% if true emergency; otherwise, not covered |
| Urgent Care Facility | Covered 100% after $25 copay per visit | Covered 100% after $25 copay per visit |
| Inpatient Mental Health | Covered 100%; 20 days per calendar year in- and out-of-network combined | Covered 80% of R&C* after deductible; 20 days per calendar year in- and out-of-network combined |
| Inpatient Substance Abuse | Covered 100% 20 days per calendar year in- and out-of-network combined |
Covered 80% of R&C* after deductible. 20 days per calendar year in- and out-of-network combined |
| Maternity — Inpatient | Covered 100% | Covered 80% of R&C* after deductible |
| Skilled Nursing Facility | Covered 100%, maximum of 60 days per calendar year in- and out-of-network combined | Covered 80% of R&C* after deductible; maximum 60 days per calendar year in- and out-of-network combined |
| Hospice Care (inpatient & outpatient) |
Covered 100%, no copay | Covered 80% of R&C* after deductible |
| Outpatient (short-term) rehabilitation Includes speech, occupational, physical, and cardiac rehabilitation |
Covered 100% after $10 copay per visit; 20-day limit per calendar year in- and out-of-network combined | Covered 80% of R&C* after deductible; maximum of 20 days per calendar year in- and out-of-network combined |
*R&C = Reasonable and customary charges in your geographic area for similar services.
Notes:
Notes:
- In-network copays will not apply toward the out-of-network annual deductibles.
- All out-of-network inpatient hospitalizations and outpatient surgeries must be pre-certified. Failure to do so will result in denied claims.
- Hospital stays not deemed medically necessary will be disapproved.
- This plan does not cover bariatric surgery (gastric bypass) and non-cancerous skin tag removal.
- This plan will cover rhinoplasty, breast reductions, varicose veins and blepharoplasty surgery (removal of excessive eyelid tissue) if medically necessary. Prior health plan approval is required. This plan change is effective Jan. 1, 2008.
| Prescription Drugs** | ||
|---|---|---|
| Services Covered | In-Network | Out-of-Network |
| Retail Prescription Drugs — up to 30-day supply |
Generic: $5 copay for a 30-day supply Preferred Brand: $15 copay for a 30-day supply Non-Preferred Brand: $35 copay for a 30-day supply |
80% of cost after $200 deductible |
| Mail Order — Home Delivery | Generic: $5 copay for each 30-day supply ($15 for 90 days) Preferred Brand: $15 copay for each 30-day supply ($45 for 90-days) Non-Preferred Brand: $35 copay for each 30-day supply ($105 for 90 days) |
Not covered |
**Pharmacy benefits for the CIGNA POS plan are through Medco.
Certain drugs may require a prior authorization in order to receive the prescription or the full quantity your doctor prescribes. For a listing of the brand names or categories that currently require a prior authorization, you may refer to the Benefits Homepage or contact Medco at 1.800.685.8869.
Certain drugs may require a prior authorization in order to receive the prescription or the full quantity your doctor prescribes. For a listing of the brand names or categories that currently require a prior authorization, you may refer to the Benefits Homepage or contact Medco at 1.800.685.8869.
| Vision Plan** | ||
|---|---|---|
| Services Covered | In-Network | Out-of-Network |
| Exam every 12 months | Covered in full | Exam – $29.75 |
| Lenses every 12 months Single vision Bifocal Trifocal Polycarbonate for dependent children |
Covered in full Covered in full Covered in full Covered in full |
Single Vision – $21.25 Bifocals – $34.00 Trifocal – $46.75 |
| Frames every 24 months | Covered up to $120 Plus, 20% off amount exceeding $120 |
Frames – $38.25 |
| — Or — | ||
| Contact Lens every 12 months | Covered up to $120, allowance applies to the cost of contacts and contact lens exam Plus, 15% off cost of contact lens exam — Or — Eligible members may take advantage of VSP Contact Lense Care Program, in which contact lens exam and up to 4 boxes (6 month supply) are covered in full |
Elective Contacts – $105 |
| Lens Options | 20% discount on lens enhancements and upgrades | |
| Additional Discounts | ||
| Additional prescription glasses and sunglasses | 20% discount | |
| Laser vision correction services | Provided at a reduced cost through VSP network doctors and contracted laser surgery centers | |
**Vision benefits for the CIGNA POS plan are through VSP.
Note: Every attempt has been made to ensure the accuracy of this summary. However, its contents are not legally binding nor should it be considered as a substitute for the actual contract language, company policies, or Your Book of Benefits.
Comparison Information for Medical Plans for 2010
Benefits being offered by the CIGNA Open Access and CIGNA POS medical plans for 2010 can be reviewed in this comparison document (pdf).