| Medical Plan Summary — 2005 CIGNA Open Access
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| |
| Services Covered |
In-Network |
Out-of-Network |
| Annual Deductible Amount for injury, illness, or maternity |
$300/individual;
$600/family
|
$500/individual;
$1,000/family
|
| Out-of-Pocket Annual Limit
(excludes deductible)
|
$1,500/individual;
$3,000/family
|
$4,500/individual;
$9,000/family
|
| Pre-Existing Conditions |
N/A |
N/A |
| Maximum Lifetime Benefit |
$2,000,000 (combined in- and out-of-network maximum) |
$2,000,000 (combined in- and out-of-network maximum) |
| Annual Reinstatement |
$5,000 (combined in- and out-of-network) |
$5,000 (combined in- and out-of-network) |
Physician Care |
| Services Covered |
In-Network |
Out-of-Network |
| Primary Care Office Visit |
Covered 100% after $15 copay |
Covered 60% of R&C* after deductible |
| Specialist Office Visit |
Covered 100% after $30 copay |
| Vision Exam |
Services provided by VSP.
No charge for yearly exam; no charge for standard frames every 24 months; no charge for standard lenses every 12 months; or reimbursement up to $75 for one pair of contact lenses (replaces all other benefits and includes exam)
|
Plan covers up to $25 toward yearly exam; up to $40 toward pair of frames every 24 months; lenses according to fee schedule or one pair of contact lenses every 12 months up to $75 (replaces all other benefits and includes exam) |
| Physician and Surgeon Services in Hospital |
Covered 90% after plan deductible |
Covered 60% of R&C* after deductible |
| Maternity Office Visits |
Covered 100% after one-time physician's office visit copay |
Covered 60% of R&C* after deductible |
| Maternity Delivery (Physician charges) |
Covered 90% after plan deductible |
Covered 60% of R&C* after deductible |
| Preventive Health Services: |
Covered 100% after: |
|
|
Well-Baby Care
|
$15 copay (including immunizations) |
Not covered |
| Routine Physical Exams |
$15 primary care office copay |
Not covered |
| Routine Gynecological Exams |
$30 physician's office copay, if physician used is contracted as specialist;
$15 physician's office copay, if physician used is contracted as primary care physician |
Not covered |
| Routine Mammogram |
No charge (no referral needed) |
Covered 60% of R&C* after deductible |
|
Hearing Aid Benefits |
$750 maximum every 36 months
|
Not covered
|
Outpatient Laboratory and
Radiology
Note: Outpatient laboratory services provided at a CIGNA contracted facility, such as Lab Corp or Spectrum, are covered at 100%
|
Covered 90% after plan deductible |
Covered 60% of R&C* after deductible |
| Home Health Care (skilled visits only) |
Covered 100% |
Covered 60% of R&C* after deductible for up to 60 visits per calendar year, reduced by any in-network visits |
| Chiropractic Care (when medically appropriate) |
Covered 100% after $30 copay; 25 visit limit per year |
Not covered |
Alcohol/Drug Detoxification:
Outpatient |
$30 copay per visit for individual therapy;
$15 copay per visit for group therapy
|
Covered 60% of R&C* after deductible; up to 35 visits limit per year |
Mental Health Service:
Outpatient
|
$30 copay per visit for individual therapy;
$15 copay per visit for group therapy
|
Covered 60% of R&C* after deductible; up to 35 visits limit per year |
| Physician Services in Emergency Room |
Covered 90% after deductible |
Covered 60% of R&C* after deductible |
| Durable Medical Equipment |
Covered 100% |
Covered 60% of R&C* after deductible |
Infertility Treatment
Physician office visit, test, counseling
Surgical Treatment:
Includes procedures for correction of infertility (invitro fertilization, artificial insemination, GIFT, ZIFT, etc.)
|
$30 copay per office visit, then covered 100%
Inpatient and outpatient facility same as inpatient and outpatient hospital
Physician services 90% after plan deductible
Limited coverage; lifetime maximum $20,000
|
60% of R&C* after plan deductible
Limited coverage; lifetime maximum $20,000
|
| External Prosthetic Devices—Requires approval by Healthplan |
Covered 90% after deductible and $100 copay |
Covered 60% of R&C* after deductible |
Hospital Care |
| Services Covered |
In-Network |
Out-of-Network |
|
Inpatient Services: |
|
|
|
Operating room, x-ray, and laboratory services;
includes stand-alone facilities such as Birthing Center
|
Covered 90% after deductible and $250 copay per visit |
Covered 60% of R&C* after deductible and $500 copay per visit |
| Room and board |
Covered at hospital's negotiated rate for semi-private room |
|
Outpatient Services:
Outpatient Facility
Physician's Office
|
Covered 90% after deductible and $150 copay per visit |
Covered 60% of R&C* after deductible and $300 copay per visit |
| Organ Transplant Coverage |
|
|
|
Inpatient Facility
|
Covered 90% after deductible and $250 copay at approved facilities |
Covered 60% of R&C* after deductible |
|
Travel Benefit
|
$10,000 per transplant per lifetime available when using an approved facility
|
Not covered
|
| Emergency Room Services |
Covered 100% after $100 copay per visit if true emergency (waived if admitted) |
Covered 100% after $100 copay per visit if true emergency (waived if admitted) |
| Ambulance Services |
Covered 100% if true emergency |
Covered 100% if true emergency; otherwise, 60% of R&C* |
| Urgent Care Facility |
Covered 100% after $50 copay per visit
|
Covered 60% of R&C* after deductible |
| Inpatient Mental Health |
Covered 90% after deductible and $250 copay per admission; 20 days per calendar year in- and out-of-network combined |
Covered 60% of R&C* after deductible; 20 days per calendar year in- and out-of-network combined |
| Inpatient Alcohol and Drug Abuse |
Covered 90% after deductible and $250 copay per admission
Limited to 2 admissions per lifetime and 100 days per lifetime in- and out-of-network combined
|
Covered 60% of R&C* after deductible
Limited to 2 admissions per lifetime and 100 days per lifetime in- and out-of-network combined
|
| Maternity - Inpatient |
Covered 90% after deductible and $250 copay for mother (includes child) |
Covered 60% of R&C* after deductible |
| Skilled Nursing Facility |
Covered 90% after deductible for up to 60 days per calendar year in- and out-of-network combined |
Covered 60% of R&C* after deductible for up to 60 days per calendar year in- and out-of-network combined |
| Hospice Care |
|
Covered 60% of R&C* after deductible |
|
Inpatient
|
Same as inpatient hospital
|
|
Outpatient
|
Covered 100%, no copay
|
| Outpatient (short-term) rehabilitation;
includes speech, occupational, physical, and cardiac rehabilitation
|
Covered 100%. 180 visits per year for all conditions for in- and out-of-network combined |
Covered 60% of R&C* after deductible. 180 visits per year for all conditions for in- and out-of-network combined |
Prescription Drugs**
|
| Services Covered |
In-Network |
Out-of-Network |
| Retail Prescription Drugs—up to 30-day supply |
- $150 deductible for salaried employees and all retirees
- $100 deductible for hourly employees
- Generic: 20% (minimum $10 copay) after deductible
- Brand: 30% (minimum $10 copay) after deductible
- If actual cost is under $10, then you pay actual cost
|
50% of cost after $150 deductible |
| Mail Order—Home Delivery |
Salaried employees and all retirees:
- Generic: $15 copay for up to a 90-day supply
- Brand: $35 copay for up to a 90-day supply
Hourly employees:
- Generic $5 copay for up to 90 day supply
- Brand: $15 copay for up to 90 day supply
|
Not covered |
This is a summary of health care provisions. Every attempt has been made to assure accuracy.
