COLORADO HEALTH PLAN DESCRIPTION FORM - Cigna

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IN-NETWORKFOR ALL CARE7a. COVERED PROVIDERS Connecticut General Life InsuranceCompany PPO Network. See providerdirectory for complete list of currentproviders.7b. With respect to network plans,are all the providers listed in 7a. Yesaccessible to me through myprimary care physician?8. ROUTINE MEDICAL OFFICEVISITS 4a) Primary Care ProvidersOpen Access Value 1500/70%Open Access Value 2500/70%Open Access Value 3000/70%Open Access Value 5000/70%Open Access Value 7500/70%Open Access Value 5000/100%$40 copay (does not apply to out-of-pocketmaximum)OUT-OF-NETWORKAll providers licensed or certified toprovide covered benefits.Not applicable50% coinsuranceOpen Access Value 10,000/70%b) SpecialistsOpen Access Value 1500/70%Open Access Value 2500/70%Open Access Value 3000/70%Open Access Value 5000/70%Open Access Value 7500/70%Open Access Value 5000/100%Open Access Value 10,000/70%9. PREVENTIVE CAREa) Adult and Children’s services(Includes routine physicals and otherroutine preventive services.)30% coinsurance$60 copay (does not apply to out-of-pocketmaximum)30% coinsurancePlan pays 100% (deductible waived)50% coinsurance50% coinsurance50% coinsurancePlan pays 100% (deductible waived)CO_Individual Open Access Value Plans Page 2 of 15Catalog No: 851836a CO 8/12
10. MATERNITYa) Pre-natal careOpen Access Value 1500/70%Open Access Value 2500/70%Open Access Value 3000/70%Open Access Value 5000/70%Open Access Value 7500/70%Open Access Value 10,000/70%Open Access Value 5000/100%IN-NETWORK30% coinsurance0% coinsuranceOUT-OF-NETWORK50% coinsurance50% coinsuranceb) Delivery & inpatient well-babycare 5Open Access Value 1500/70%Open Access Value 2500/70%Open Access Value 3000/70%Open Access Value 5000/70%Open Access Value 7500/70%Open Access Value 10,000/70%Open Access Value 5000/100%$500 additional deductible peradmission, (does not apply to out-ofpocketmaximum), 30% coinsurance$500 additional deductible peradmission, (does not apply to out-ofpocketmaximum), 0% coinsurance$1,000 additional deductible peradmission, (does not apply to out-ofpocketmaximum),50% coinsurance$1,000 additional deductible peradmission, (does not apply to out-ofpocketmaximum),50% coinsurance11. PRESCRIPTION DRUGS 6(Pharmacy charges do not apply to out-ofpocketmaximum.)Brand Name Drug Deductible(Combined in- and out-of-network, this is aseparate deductible from the AnnualDeductible amount and does not apply toout-of-pocket maximum.)Open Access Value 1500/70%Open Access Value 2500/70%Open Access Value 3000/70%Open Access Value 5000/70%Open Access Value 7500/70%Open Access Value 10,000/70%Open Access Value 5000/100%Members must show <strong>Cigna</strong> ID card when filling prescriptions at both in- and out-of-networkpharmacies. For drugs on the <strong>Cigna</strong>-approved list, contact Member Servicesat 1-800-244-6224.$500$500$500$500$500$500$500Preventive DrugsPreventive Drugs designated by thePatient Protection and Affordable CareAct of 2010Plan pays 100% (deductible waived)50% coinsuranceGeneric (except as noted underPreventive Drugs) (30-day supply)Brand (30-day supply)Non-preferred (30-day supply)Self Injectable$15 copay 50% coinsurance$40 copay (subject to brand name drug deductible) 50% coinsurance$65 copay (subject to brand name drug deductible) 50% coinsurance30% coinsurance 50% coinsuranceMail Order Drugs (90-day supply)CO_Individual Open Access Value Plans Page 3 of 15Catalog No: 851836a CO 8/12
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COLORADO HEALTH PLAN DESCRIPTION FORM - Cigna

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