2014 Cigna HRA Summary of Benefits and Coverage (SBC) - Hospira

Cigna: Hospira HRA Plus Medical Plan Coverage Period: 01/01/2014 – 12/31/2014Summary of Benefits and Coverage: What this Plan Covers & What it CostsYour Cost IfCommonServices You May NeedYou Use anMedical EventIn-networkProviderIf you need helprecovering or haveother special healthneeds(continued)If your child needsdental or eye careSkilled nursing care 20% co-insurance 40% co-insuranceDurable medical equipment 20% co-insurance 40% co-insuranceCoverage for: All Coverage Tiers | Plan Type: HRAYour Cost If YouUse anLimitations & ExceptionsOut-of-networkProvider120 days per calendar year. CombinedIn and Out-of-Network.Some limitations apply. Check yourpolicy or plan document for detailsHospice service 20% co-insurance 40% co-insurance No limit per lifetimeEye exam Not Covered Not CoveredGlasses Not Covered Not CoveredDental check-up Not Covered Not CoveredExcluded Services & Other Covered Services:Coverage available in the VoluntaryVision plan (if elected)Coverage available in the VoluntaryVision plan (if elected)Coverage available in the VoluntaryDental plan (if elected)Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)• Acts of war/military duty• Certain foot care• Cosmetic medication• Cosmetic surgery• Custodial/convalescent care• Diagnostic hospital confinement• Hearing aids & hearing devices• Non-accidental injury dental care• Non-emergency care when traveling outsidethe U.S.• Weight reduction programsOther Covered Services (This isn’t a complete list. Check your policy or plan document for details, other covered services and your costs forthese services.)• Acupuncture (if rendered by a licensedprovider & are in lieu of traditionalanesthesia)• Allergy Testing & Treatment• Bariatric surgery (network is limited toCenters of Excellence)Questions: Call 1-800-Cigna24 or visit us at www.mycigna.com.If you aren’t clear about any of the underlined terms used in this form, see the Glossary.You can view the Glossary at www.ccio.cms.gov or call 1-800-Cigna24 to request a copy.• Speech therapy (30 days per calendar year )• Emergency coverage provided outside theUnited States.5 of 8