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

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BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK Combined Medical/Pharmacy Outof-Pocket Maximum Combined Medical/Pharmacy Outof-Pocket: includes retail and home delivery prescription drugs Home Delivery Pharmacy Costs Contribute to the Combined Medical/Pharmacy Out-of-Pocket Maximum Physician’s Services Yes Yes Yes In-Network coverage only Primary Care Physician’s Office visit 90% after plan deductible 70% after plan deductible Specialty Care Physician’s Office Visits Consultant and Referral Physician’s Services Note: OB/GYN providers will be considered either as a PCP or Specialist, depending on how the provider contracts with the Insurance Company. Surgery Performed In the Physician’s Office Second Opinion Consultations (provided on a voluntary basis) 90% after plan deductible 70% after plan deductible 90% after plan deductible 70% after plan deductible 90% after plan deductible 70% after plan deductible Allergy Treatment/Injections 90% after plan deductible 70% after plan deductible Allergy Serum (dispensed by the Physician in the office) 90% after plan deductible 70% after plan deductible Preventive Care Routine Preventive Care - all ages No charge 70% after plan deductible Immunizations - all ages No charge 70% after plan deductible Mammograms, PSA, PAP Smear Preventive Care Related Services (i.e. “routine” services) Diagnostic Related Services (i.e. “non-routine” services) No charge Subject to the plan’s x-ray & lab benefit; based on place of service 70% after plan deductible Subject to the plan’s x-ray & lab benefit; based on place of service 14 my<strong>CIGNA</strong>.com
BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK Inpatient Hospital - Facility Services 90% after plan deductible 70% after plan deductible Semi-Private Room and Board Limited to the semi-private room Limited to the semi-private room rate negotiated rate Private Room Limited to the semi-private room Limited to the semi-private room rate negotiated rate Special Care Units (ICU/CCU) Limited to the negotiated rate Limited to the ICU/CCU daily room rate Outpatient Facility Services Operating Room, Recovery Room, Procedures Room, Treatment Room and Observation Room Inpatient Hospital Physician’s Visits/Consultations Inpatient Hospital Professional Services 90% after plan deductible 70% after plan deductible 90% after plan deductible 70% after plan deductible 90% after plan deductible 70% after plan deductible Surgeon Radiologist Pathologist Anesthesiologist Outpatient Professional Services 90% after plan deductible 70% after plan deductible Surgeon Radiologist Pathologist Anesthesiologist 15 my<strong>CIGNA</strong>.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 12 and 13: Assistant Surgeon and Co-Surgeon Ch
Page 16 and 17: 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: once to better understand side effe

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

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