COLORADO HEALTH PLAN DESCRIPTION FORM - Cigna

More documents

Recommendations

Info

convalescent care.CO_Individual Open Access Value Plans Page 10 of 15Catalog No: 851836a CO 8/12BENEFIT LEVELSInpatient room and board charges in connection with a Hospital stayprimarily for diagnostic tests which could have been performed safelyon an outpatient basis.Treatment of Mental, Emotional or Functional Nervous Disorders orpsychological testing except as specifically provided in this Policy.However, medical conditions that are caused by behavior of the InsuredPerson and that may be associated with these mental conditions are notsubject to these limitations.Smoking cessation programs.Treatment of substance abuse, except as specifically provided in thisPolicy.Dental services, dentures, bridges, crowns, caps or other DentalProstheses, extraction of teeth or treatment to the teeth or gums, except asspecifically provided in this Policy.Orthodontic Services, braces and other orthodontic appliances includingorthodontic services for Temporomandibular Joint Dysfunction.Dental Implants: Dental materials implanted into or on bone or soft tissueor any associated procedure as part of the implantation or removal ofdental implants.Hearing aids, except as specifically stated in this Policy.Routine hearing tests except as specifically provided in this Policyunder “Comprehensive Benefits, What the Plan Pays For”.Genetic screening or pre-implantations genetic screening: generalpopulation-based genetic screening is a testing method performed inthe absence of any symptoms or any significant, proven risk factorsfor genetically linked inheritable disease.Optometric services, eye exercises including orthoptics, eyeglasses,contact lenses, routine eye exams, and routine eye refractions, except asspecifically stated in this Policy.An eye surgery solely for the purpose of correcting refractive defects ofthe eye, such as near-sightedness (myopia), astigmatism and/orfarsightedness (presbyopia).Any Drugs, medications, or other substances dispensed or administered inany outpatient setting except as specifically stated in this Policy. Thisincludes, but is not limited to, items dispensed by a Physician.Cosmetic surgery or other services for beautification, to improve or alterappearance or self esteem or to treat psychological or psychosocialcomplaints regarding one's appearance including macromastia orgynecomastia surgeries; surgical treatment of varicose veins;abdominoplasty/panniculectomy; rhinoplasty; and blepharoplasty,. Thisexclusion does not apply to Reconstructive Surgery to restore a bodilyfunction or to correct a deformity caused by Injury or congenital defect ofa Newborn child, or for Medically Necessary Reconstructive Surgeryperformed to restore symmetry incident to a mastectomy.Aids or devices that assist with nonverbal communication, including but notlimited to communication boards, prerecorded speech devices, laptopcomputers, desktop computers, Personal Digital Assistants (PDAs), Braille
BENEFIT LEVELStypewriters, visual alert systems for the deaf and memory books.Non-medical counseling or ancillary services, including but not limited to:education, training, vocational rehabilitation, behavioral training,biofeedback, neurofeedback, hypnosis, sleep therapy, employmentcounseling, back school, return to work services, work hardening programs,driving safety, and services, training, educational therapy or other nonmedicalancillary services for learning disabilities and developmentaldelays.Services for redundant skin surgery, removal of skin tags, acupressure,acupuncture, carinosacral/cranial therapy, dance therapy, movementtherapy, applied kinesiology, rolfing, prolotherapy and extracorporeal shockwave lithotripsy (ESWL) for musculoskeletal and orthopedic conditions,regardless of clinical indications.Procedures or treatments to change characteristics of the body to those ofthe opposite sex. This includes any medical, surgical or psychiatrictreatment or study related to sex change.Treatment of sexual dysfunction impotence and/or inadequacy except ifthis is a result of an Accidental Injury, organic cause, trauma, infection, orcongenital disease or anomalies.All services related to the evaluation or treatment of fertility and/orInfertility, including, but not limited to, all tests, consultations,examinations, medications, invasive, medical, laboratory or surgicalprocedures including sterilization reversals and In vitro fertilization, exceptas specifically stated in this Plan.All non-prescription Drugs, devices and/or supplies, except drugsdesignated as preventive by the Patient Protection and Affordable Care Act(PPACA), that are available over the counter or without a prescription,Cryopreservation of sperm or eggs.Fees associated with the collection or donation of blood or bloodproducts, except for autologous donation in anticipation of scheduledservices where in the utilization review Physician’s opinion the likelihoodof excess blood loss is such that transfusion is an expected adjunct tosurgery.Blood administration for the purpose of general improvement inphysical conditionOrthopedic shoes (except when joined to braces) or shoe inserts, includingorthotics.Services primarily for weight reduction or treatment of obesity includingmorbid obesity, or any care which involves weight reduction as a mainmethod for treatment. This includes any morbid obesity surgery, even if theInsured Person has other health conditions that might be helped by areduction of obesity or weight, or any program, product or medicaltreatment for weight reduction or any expenses of any kind to treat obesity,weight control or weight reduction.Routine physical exams or tests that do not directly treat an actualCO_Individual Open Access Value Plans Page 11 of 15Catalog No: 851836a CO 8/12
Page 2 and 3: IN-NETWORKFOR ALL CARE7a. COVERED P
Page 4 and 5: Preventive DrugsPreventive Drugs de
Page 6 and 7: Open Access Value 10,000/70%IN-NETW
Page 8 and 9: Open Access Value 3000/70%Open Acce
Page 12 and 13: CO_Individual Open Access Value Pla
Page 14 and 15: 43. Does the plan have a bindingarb

COLORADO HEALTH PLAN DESCRIPTION FORM - Cigna

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?