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

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BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK Maternity Care Services Initial Visit to Confirm Pregnancy 90% after plan deductible 70% after plan deductible Note: OB/GYN providers will be considered either a PCP or Specialist depending on how the provider contracts with the Insurance Company. All subsequent Prenatal Visits, Postnatal Visits and Physician’s Delivery Charges (i.e. global maternity fee) Physician’s Office Visits in addition to the global maternity fee when performed by an OB/GYN or Specialist Delivery - Facility (Inpatient Hospital, Birthing Center) 90% after plan deductible 70% after plan deductible 90% after plan deductible 70% after plan deductible 90% after plan deductible 70% after plan deductible Abortion Includes elective and non-elective procedures Physician’s Office Visit 90% after plan deductible 70% after plan deductible Inpatient Facility 90% after plan deductible 70% after plan deductible Outpatient Facility 90% after plan deductible 70% after plan deductible Physician’s Services 90% after plan deductible 70% after plan deductible Family Planning Services Office Visits, Lab and Radiology Tests and Counseling 90% after plan deductible 70% after plan deductible Note: The standard benefit will include coverage for contraceptive devices (e.g. Depo-Provera and Intrauterine Devices (IUDs). Diaphragms will also be covered when services are provided in the physician’s office. Surgical Sterilization Procedure for Vasectomy/Tubal Ligation (excludes reversals) Physician’s Office Visit 90% after plan deductible 70% after plan deductible Inpatient Facility 90% after plan deductible 70% after plan deductible Outpatient Facility 90% after plan deductible 70% after plan deductible Physician’s Services 90% after plan deductible 70% after plan deductible 18 myCIGNA.com
BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK Infertility Treatment Coverage will be provided for the following services: • Testing and treatment services performed in connection with an underlying medical condition. • Testing performed specifically to determine the cause of infertility. • Treatment and/or procedures performed specifically to restore fertility (e.g. procedures to correct an infertility condition). Surgical Treatment: Limited to procedures for the correction of infertility (excludes Artificial Insemination, In-vitro, GIFT, ZIFT, etc.) Physician’s Office Visit (Lab and Radiology Tests, Counseling) 90% after plan deductible 70% after plan deductible Inpatient Facility 90% after plan deductible 70% after plan deductible Outpatient Facility 90% after plan deductible 70% after plan deductible Physician’s Services 90% after plan deductible 70% after plan deductible Organ Transplants Includes all medically appropriate, nonexperimental transplants Physician’s Office Visit 90% after plan deductible 70% after plan deductible Inpatient Facility Physician’s Services Lifetime Travel Maximum: $10,000 per transplant Durable Medical Equipment Contract Year Maximum: . Unlimited External Prosthetic Appliances Contract Year Maximum: . Unlimited Nutritional Evaluation Contract Year Maximum: 3 visits per person 100% at Lifesource center after plan deductible, otherwise 90% after plan deductible 100% at Lifesource center after plan deductible, otherwise 90% after plan deductible No charge (only available when using Lifesource facility) 70% after plan deductible 70% after plan deductible In-Network coverage only 90% after plan deductible 70% after plan deductible 90% after plan deductible 70% after plan deductible Physician’s Office Visit 90% after plan deductible 70% after plan deductible Inpatient Facility 90% after plan deductible 70% after plan deductible Outpatient Facility 90% after plan deductible 70% after plan deductible Physician’s Services 90% after plan deductible 70% after plan deductible 19 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 12 and 13: Assistant Surgeon and Co-Surgeon Ch
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: once to better understand side effe

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