This is a summary of benefits
for your Open Access Plus plan. All deductibles and plan out-of-pocket maximums
accumulate in one direction toward in-network unless otherwise noted. Plan maximums and service-specific maximums
(dollar and occurrence) cross-accumulate between in- and out-of-network unless
otherwise noted.
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CIGNA HealthCare Benefit Summary 2007 Open Access Plus Coinsurance Plan High Deductible Plan |
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BENEFIT HIGHLIGHTS |
IN-NETWORK |
OUT-OF-NETWORK |
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Lifetime
Maximum |
Unlimited |
Unlimited |
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Coinsurance
Levels |
90% |
70%
of Reasonable & Customary |
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Calendar
Year Deductible Individual Family Maximum Aggregate |
$1,000
per person $2,000
per family Yes |
$2,000
per person $4,000
per family Yes |
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Annual Out-of-Pocket
Maximum Includes Deductible Includes Copays Individual |
No No $3,000 per
person |
No No $6,000 per
person |
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Family Maximum |
$6,000 per
family |
$12,000
per family |
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Aggregate Does not apply to: Benefits for accident or sickness (excludes mental
health, alcohol and drug abuse benefits) are paid at 100% of charges once an
individual's out-of-pocket has been reached. |
Yes Non-compliance penalties,
deductibles, copays or charges for mental health,
alcohol and drug abuse benefits. |
Yes Non-compliance penalties,
deductibles, copays or charges for mental
health, alcohol and drug abuse benefits or charges in excess of Reasonable
and Customary |
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Automated
Annual Reinstatement |
Not Applicable |
Not
Applicable |
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Physician's Services |
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Primary Care
Physician's Office visit |
90% after plan
deductible; 90% after plan deductible for x-ray/lab if billed by a separate
outpatient diagnostic facility such as a hospital |
70% after plan
deductible |
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Specialty Care Physician's Office Visit Office Visits Consultant and Referral Physician's Services |
90% after plan
deductible; 90% after plan deductible for x-ray/lab if billed by a separate
outpatient diagnostic facility such as a hospital |
70% after plan
deductible |
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Surgery Performed In the Physician's Office |
90% after plan
deductible |
70% after plan
deductible |
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Allergy Treatment/Injections |
90% after plan
deductible |
70% after plan
deductible |
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Allergy
Serum (dispensed by the physician in the office) |
90% after plan deductible |
70% after plan deductible |
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Preventive Care Routine Preventive Care – Well Baby, Well-child and Adult
Preventive Care |
No charge; no
plan deductible for x-ray/lab if billed by a separate outpatient diagnostic
facility such as an outpatient hospital facility or independent facility. |
70% after plan
deductible |
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Immunizations: |
No charge; no
plan deductible |
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Routine
Mammograms, PSA, Pap Smear |
No
charge; no plan deductible |
70%
after plan deductible |
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Second Opinions (Services will be provided
on a voluntary basis) |
90% after plan deductible; 90% after plan
deductible for x-ray/lab if billed by a separate outpatient diagnostic
facility such as a hospital. |
70% after plan deductible |
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Outpatient
Pre-Admission Testing Primary Care Physician’s Office Visit |
90% after plan
deductible; 90% after plan deductible for x-ray/lab if billed by separate
outpatient diagnostic facility such as a hospital |
70% after plan
deductible |
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Specialist Physician’s Office Visit |
90% after plan
deductible; 90% after plan deductible for x-ray/lab if billed by separate
outpatient diagnostic facility such as a hospital |
70% after plan
deductible |
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90% after plan
deductible |
70% after plan
deductible |
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Independent
X-ray and Lab Facility |
90% after plan deductible |
70% after plan deductible |
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90% after plan
deductible |
70% after plan
deductible |
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Semi Private Room and Board |
Limited to
semi-private room negotiated rate |
Limited to
semi-private room rate |
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Private Room |
Limited to
semi-private room negotiated rate |
Limited to
semi-private room rate |
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Special
Care Units (ICU/CCU) |
Limited to negotiated rate |
Limited ICU/CCU daily room rate |
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Outpatient
Facility Services Operating Room,
Recovery Room, Procedure Room and Treatment Room |
90%
after plan deductible |
70%
after plan deductible |
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Inpatient
Hospital Physician’s Visits/Consultations |
90% after plan deductible |
70% after plan deductible |
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90% after plan deductible |
70% after plan deductible |
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Multiple Surgical Reduction |
n
Multiple surgeries performed during one
operating session result in payment reduction of 50% of charges to the
surgery of lesser charge. The most
expensive procedure is paid as any other surgery. |
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Outpatient Professional Services Surgeon Radiologist Pathologist Anesthesiologist |
90% after plan deductible |
70% after plan deductible |
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Emergency and Urgent
Care Services Physician’s Office |
90% after plan
deductible |
90% after plan
deductible (except if not a true emergency, then 70% after plan deductible). |
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Hospital Emergency Room |
90% after plan
deductible |
90% after plan
deductible (except if not a true emergency, then 70% after plan deductible) |
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Urgent Care Facility
or Outpatient Facility |
90% after plan
deductible |
90% after plan
deductible (except if not a true emergency, then 70% after plan deductible) |
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Ambulance |
90%
after plan deductible** **If
not a true emergency, services are not covered |
90% after plan deductible ** (except if not a true emergency, then 70%
after plan deductible) **If
not a true emergency, services are not covered |
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Inpatient
Services at Other Health Care Facilities Includes Skilled
Nursing Facility, 60 days combined maximum per calendar year. No prior hospitalization required. |
90%
after plan deductible |
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