| Medical Plan Summary — 2005 CIGNA Point of Service
|
| |
| Services Covered |
In-Network |
Out-of-Network |
| Annual Deductible Amount for injury, illness, or maternity |
None
|
$200/individual;
$400/family
|
| Out-of-Pocket Annual Limit
(excludes deductible)
|
$1,000/individual;
$2,000/family
|
$3,000/individual;
$6,000/family
|
| Pre-Existing Conditions |
N/A |
N/A |
| Maximum Lifetime Benefit |
Unlimited |
$2,000,000 lifetime |
| Annual Reinstatement |
NA |
NA |
Physician Care |
| Services Covered |
In-Network |
Out-of-Network |
| Primary Care Office Visit; Specialist Office Visit |
Covered 100% after $10 copay |
Covered 80% of R&C* after deductible |
| Vision Exam |
Services provided by VSP.
Vision Exam - covered 100% after $10 copay - yearly exam
Eyewear Allowance: $150 allowance every 12 months for children up through age 17; every 24 months for age 18 and over
|
Not covered |
| Physician and Surgeon Services in Hospital |
Covered 100% |
Covered 80% of R&C* after deductible |
| Maternity Office Visits |
Covered 100% after one-time physician's office visit copay |
Covered 80% of R&C* after deductible |
| Maternity Delivery (Physician charges) |
Covered 100% |
Covered 80% of R&C* after deductible |
| Preventive Health Services: |
Covered 100% after: |
|
|
Well-Baby Care
|
$10 copay (including immunizations) |
Not covered |
| Routine Physical Exams |
$10 copay |
Not covered |
| Routine Gynecological Exams |
$10 copay |
Not covered |
| Routine Mammogram |
No charge (no referral needed) |
Covered 80% of R&C* after deductible |
|
Hearing Aid Benefits |
Not covered
|
Not covered
|
| Outpatient Laboratory and
Radiology
|
Covered 100% |
Covered 80% of R&C* after deductible |
| Home Health Care (skilled visits only) |
Covered 100%; up to 60 visits per calendar year, in- and out-of-network combined |
Covered 80% of R&C* after deductible; up to 60 visits per calendar year, in- and out-of-network combined |
| Chiropractic Care (when medically appropriate) |
Covered 100% after $10 copay per visit with PCP referral; 25 visit limit per year |
Not covered |
Alcohol/Drug Detoxification:
Outpatient |
$10 copay per visit for individual therapy;
$10 copay per visit for group therapy; 35 visit limit per calendar year in-and out-of-network combined
|
Covered 80% of R&C* after deductible; 35 visit limit per calendar year in- and out-of-network combined |
Mental Health Service:
Outpatient
|
Covered 100% after $10 copay per visit; 35 visit limit per calendar year, in- and out-of-network combined
|
Covered 80% of R&C* after deductible; 35 visit limit per calendar year, in- and out-of-network combined |
| Physician Services in Emergency Room |
Covered 100% |
Covered 80% of R&C* after deductible |
| Durable Medical Equipment |
Covered 100%, maximum of $3,500 per calendar year |
Not covered |
Infertility Treatment
Physician office visit, test, counseling
Surgical Treatment:
Includes procedures for correction of infertility (invitro fertilization, artificial insemination, GIFT, ZIFT, etc.)
|
Not covered
|
Not covered
|
| External Prosthetic Devices—Requires approval by Healthplan |
Covered 100% after $200 deductible; maximum of $1,000 per calendar year |
Not covered |
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 100%, no copay
|
Covered 80% of R&C* after deductible
|
| Outpatient Services |
|
|
|
Outpatient Facility
|
Covered 100% |
Covered 80% of R&C* after deductible |
|
Physician's Office
|
Covered 100% after $10 office visit copay per visit
|
Covered 80% of R&C* after deductible
|
| Organ Transplant Coverage |
|
|
|
Inpatient Facility
|
Covered 100% at approved facilities |
Not covered |
|
Travel Benefit
|
$10,000 per transplant per lifetime available when using an approved facility
|
Not covered
|
| Emergency Room Services |
Covered 100% after $50 copay if true emergency (waived if admitted) |
Covered 100% after $50 copay if true emergency (waived if admitted) |
| Ambulance Services |
Covered 100% if true emergency; otherwise not covered |
Covered 100% if true emergency; otherwise, not covered |
| Urgent Care Facility |
Covered 100% after $25 copay
|
Covered 80% of R&C* after deductible |
| Inpatient Mental Health |
Covered 100%; 20 days per calendar year in- and out-of-network combined |
Covered 80% of R&C* after deductible; 20 days per calendar year in- and out-of-network combined |
| Inpatient Alcohol and Drug Abuse |
Covered 100%
20 days per calendar year in- and out-of-network combined
|
Covered 80% of R&C* after deductible
20 days per calendar year in- and out-of-network combined
|
| Maternity - Inpatient |
Covered 100% |
Covered 80% of R&C* after deductible |
| Skilled Nursing Facility |
Covered 100%; maximum of 60 days per calendar year in- and out-of-network combined |
Covered 80% of R&C* after deductible; maximum 60 days per calendar year in- and out-of-network combined |
| Hospice Care (inpatient and outpatient)
|
Covered 100%, no copay
|
Covered 80% of R&C* after deductible |
| Outpatient (short-term) rehabilitation;
includes speech, occupational, physical, and cardiac rehabilitation
|
Covered 100% after $10 copay per visit; 20 visit limit per calendar year in- and out-of-network combined |
Covered 80% of R&C* after deductible; maximum of 20 visits per calendar year in- and out-of-network combined |
Prescription Drugs**
|
| Services Covered |
In-Network |
Out-of-Network |
| Retail and Mail Order—Home Delivery |
- Generic: $5 copay for each 30-day supply ($15 for 90 days)
- Brand: $15 copay for each 30-day supply ($45 for 90 days)
- Select: $35 copay for each 30-day supply ($105 for 90 days)
|
Not covered |
This is a summary of health care provisions. Every attempt has been made to assure accuracy.
