CIGNA High Deductible Health Plan (HDHP) - UCAR Finance ...

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Assistant Surgeon and Co-Surgeon Charges Assistant Surgeon Open Access Plus Medical Benefits The Schedule The maximum amount payable will be limited to charges made by an assistant surgeon that do not exceed 20 percent of the surgeon’s allowable charge. (For purposes of this limitation, allowable charge means the amount payable to the surgeon prior to any reductions due to coinsurance or deductible amounts). Co-Surgeon The maximum amount payable will be limited to 62.5 percent of the surgeon’s allowable charge. (For purposes of this limitation, allowable charge means the amount payable to the surgeons prior to any reductions due to coinsurance or deductible amounts.) BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK Lifetime Maximum The Percentage of Covered Expenses the Plan Pays Note: "No charge" means an insured person is not required to pay Coinsurance. Unlimited 90% 70% of the Maximum Reimbursable Charge Maximum Reimbursable Charge Maximum Reimbursable Charge is determined based on the lesser of the provider’s normal charge for a similar service or supply; or A percentile of charges made by providers of such service or supply in the geographic area where the service is received. These charges are compiled in a database we have selected. Note: The provider may bill you for the difference between the provider’s normal charge and the Maximum Reimbursable Charge, in addition to applicable deductibles, copayments and coinsurance. Not Applicable 80th Percentile 12 myCIGNA.com
BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK Contract Year Deductible Individual $3,100 per person $3,100 per person Family Maximum $6,250 per family $6,250 per family Family Maximum Calculation Individual Calculation: Family members meet only their individual deductible and then their claims will be covered under the plan coinsurance; if the family deductible has been met prior to their individual deductible being met, their claims will be paid at the plan coinsurance. Combined Medical/Pharmacy Contract Year Deductible Combined Medical/Pharmacy Deductible: includes retail and home delivery prescription drugs Home Delivery Pharmacy Costs Contribute to the Combined Medical/Pharmacy Deductible Out-of-Pocket Maximum Yes Yes Yes In-Network coverage only Individual $3,500 per person $6,000 per person Family Maximum $7,000 per family $12,000 per family Family Maximum Calculation Individual Calculation: Family members meet only their individual Out-of-Pocket and then their claims will be covered at 100%; if the family Out-of-Pocket has been met prior to their individual Out-of- Pocket being met, their claims will be paid at 100%. 13 myCIGNA.com
Page 1: University Corporation for Atmosphe
Page 4 and 5: Women’s Health and Cancer Rights
Page 6 and 7: Explanation of Terms You will find
Page 8 and 9: provided by other parties to the Po
Page 10 and 11: In addition, if at any time a Prima
Page 14 and 15: BENEFIT HIGHLIGHTS IN-NETWORK OUT-O
Page 22 and 23: • inpatient services at any parti
Page 24 and 25: • are unable to obtain the requir
Page 26 and 27: • counseling for occupational pro
Page 28 and 29: covered subject to the following co
Page 30 and 31: Prescription Drug Benefits For You
Page 32 and 33: • treatment of an Injury or Sickn
Page 34 and 35: Coordination of Benefits This secti
Page 36 and 37: Medicare Eligibles CIGNA will pay a
Page 38 and 39: Recovery of Overpayment When an ove
Page 40 and 41: in the Plan. You must request enrol
Page 42 and 43: If a child placed for adoption is n
Page 44 and 45: of the request. If more time is nee
Page 46 and 47: advance of the Committee’s decisi
Page 48 and 49: Medicare (Part A, Part B or both) w
Page 50 and 51: Trade Act of 2002 The Trade Act of
Page 52 and 53: In addition, if you disagree with t
Page 54 and 55: Employee The term Employee means a
Page 56 and 57: • rendered in the least intensive
Page 58 and 59: for injectables covered under the p
Page 60 and 61: What You Should Know about CIGNA Ch
Page 62:
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