|
CIGNA Indemnity Plan
|
| |
| Annual Deductible Amount for injury, illness or maternity |
.5% of annual pension benefit/individual (minimum $200)
1.50% of annual pension benefit/family (minimum $400) |
| Out-of-Pocket Annual Limit (includes deductible) |
5% of annual pension benefit/individual (minimum $2,000)
8% of annual pension benefit/family (minimum $4,000) |
| Pre-Existing Conditions |
n/a |
| Maximum Lifetime Benefit |
$1,000,000 |
| Annual Reinstatement |
$5,000 |
Hospital Care |
| Services Covered |
| Inpatient Services: semiprivate room, operating room, X-ray, and laboratory services |
Covered 80% of R&C after deductible |
Outpatient Services:
 |
Outpatient surgery |
|
X-ray and laboratory services |
|
Covered 80% of R&C after deductible |
| Transplant Coverage |
Covered 80% of R&C after deductible |
| Emergency Room |
Covered 80% of R&C after deductible |
| Inpatient Mental Health |
Covered 80% of R&C after deductible, limit 20 inpatient days per calendar year |
| Inpatient Substance Abuse — Limited to 2 inpatient treatments per lifetime |
Covered 80% of R&C after deductible, limit 60 inpatient days per lifetime |
| Maternity — Inpatient |
Covered 80% of R&C after deductible |
| Skilled Nursing Facility (short-term); 60 days per calendar year |
Covered 100% of R&C, no deductible if admitted in lieu of hospital confinement for up to 60 days |
| Ambulance Services |
Covered 80% of R&C after deductible if medically necessary |
| Hospice Care |
Covered 100% of R&C, inpatient limited to 60 days per lifetime |
| Outpatient short-term rehabilitiation 60 visits. Includes physical, speech, and occupational therapy |
Covered 80% of R&C after deductible |
Physician Care |
| Services Covered |
| Physician Office Visit |
Covered 80% of R&C after deductible |
| Emergency Care of Doctor's Office |
Covered 100% of R&C |
| Urgent Care Facility |
Covered 100% of R&C if care is received within 48 hours of the accident or onset of illness |
| Physician and Surgeon Services in Hospital |
Covered 80% of R&C after deductible |
| Maternity Office Visits |
Covered 80% of R&C after deductible |
| Maternity Delivery (physician charges) |
Covered 80% of R&C after deductible |
Preventive Health Services:
| 1. |
Well-Baby Care |
| 2. |
Periodic Health Assessments |
| 3. |
Routine Gynecological Exams |
| 4. |
Routine Mammogram |
| 5. |
Hearing Aid Benefits |
|
1. Not covered |
| 2. Not covered |
| 3. Not covered |
| 4. Covered 80% of R&C after deductible |
| 5. Not covered |
| Laboratory and X-ray |
Covered 80% of R&C after deductible |
| Home Health Care (skilled visits only) |
Covered 100% of R&C, no deductible if admitted in lieu of
hospital confinement for up to 60 visits per calendar year |
| Chiropractic Care |
Covered 80% of R&C after deductible;
25 visit limit per year |
Alcohol/Drug Detoxification:
| Outpatient |
|
Covered 80% of R&C after deductible; 30 visit limit per year |
Mental Health Service:
| Outpatient |
|
Covered 80% of R&C after deductible; 30 visit limit per year |
| Physician Services in Emergency Room |
Covered 80% of R&C after deductible |
| Durable Medical Equipment |
Covered 80% of R&C after deductible |
| Infertility Treatment |
Limited Coverage |
| External Prosthetic Devices — Requires approval by Health Plan |
Covered 80% of R&C after deductible |
Prescription Drugs
|
| For Prescription Drug benefit information, please refer to the Prescription Drug section |
