866103 Sbc Mycigna Health Flex 1250 North Carolina Oap 0314

User Manual: 866103

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Cigna Health and Life Insurance Company: NC myCigna Health Flex 1250 Coverage Period: 1/1/14-12/31/14
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Family | Plan Type: OAP
Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary.
You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy.
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document
at www.myCigna.com or by calling 1-800-Cigna24.
Important Questions Answers Why this Matters:
What is the overall
deductible?
For in-network providers $1,250 person/
$2,500 family
For out of-network providers $2,500 person/
$5,000 family
Does not apply to in-network preventive care,
in-network dental care for children and eye
exam for children.
You must pay all the costs up to the deductible amount before this plan begins to
pay for covered services you use. Check your policy or plan document to see when
the deductible starts over (usually, but not always, January 1st). See the chart
starting on page 2 for how much you pay for covered services after you meet the
deductible.
Are there other
deductibles for specific
services?
No. You don’t have to meet deductibles for specific services, but see the chart starting
on page 2 for other costs for services this plan covers.
Is there an out–of–
pocket limit on my
expenses?
Yes, For in-network providers $2,500 person/
$5,000 family
For out-of-network providers $5,000 person/
$10,000 family
The out-of-pocket limit is the most you could pay during a coverage period (usually
one year) for your share of the cost of covered services. This limit helps you plan for
health care expenses.
What is not included in
the out–of–pocket
limit?
Premium, balanced-billed charges, penalties
for failure to obtain pre-authorization for
services, and health care this plan doesn’t
cover
Even though you pay these expenses, they don’t count toward the out-of-pocket
limit.
Is there an overall
annual limit on what
the plan pays?
No. The chart starting on page 2 describes any limits on what the plan will pay for specific
covered services, such as office visits
Does this plan use a
network of providers?
Yes. For a list of participating providers, see
www.myCigna.com or call
1-800-Cigna24
If you use an in-network doctor or other health care provider, this plan will pay some
or all of the costs of covered services. Be aware, your in-network doctor or hospital
may use an out-of-network provider for some services. Plans use the term in-
network, preferred, or participating for providers in their network. See the chart
starting on page 2 for how this plan pays different kinds of providers
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Cigna Health and Life Insurance Company: NC myCigna Health Flex 1250 Coverage Period: 1/1/14-12/31/14
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Family | Plan Type: OAP
Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary.
You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy.
Do I need a referral to
see a specialist?
No. You don’t need a referral to see a
specialist You can see the specialist you choose without permission from this plan.
Are there services this
plan doesn’t cover? Yes. Some of the services this plan doesn’t cover are listed on page 5. See your policy or
plan document for additional information about excluded services.
• Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
• Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s
allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your
deductible.
• The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed
amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount
is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
•
This plan may encourage you to use participating_ providers by charging you lower deductibles, copayments and coinsurance amounts.
Common
Medical Event Services You May Need
Your Cost If
You Use an
In-network
Provider
Your Cost If
You Use an
Out-of-network
Provider
Limitations & Exceptions
If you visit a health
care provider’s office
or clinic
Primary care visit to treat an injury or illness
$20 co-pay/visit
50% co-insurance
Specialist visit
$40 co-pay/visit
50% co-insurance
Other practitioner office visit
$40 co-pay/visit
50% co-insurance
Preventive care/screening/immunization
No charge
30% co-insurance
If you have a test
Diagnostic test (x-ray, blood work)
20% co-insurance
50% co-insurance
Imaging (CT/PET scans, MRIs) 20% co-insurance 50% co-insurance
Cigna24. Out-of-network cost share
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Cigna Health and Life Insurance Company: NC myCigna Health Flex 1250 Coverage Period: 1/1/14-12/31/14
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Family | Plan Type: OAP
Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary.
You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy.
Common
Medical Event Services You May Need
Your Cost If
You Use an
In-network
Provider
Your Cost If
You Use an
Out-of-network
Provider
Limitations & Exceptions
If you need drugs to
treat your illness or
condition
More information about
prescription drug
coverage is available
www.mycigna.com.
Tier 1 – Preferred generic drugs
$4 copay (retail) /
$10 copay (home
delivery)
50% co-insurance
(retail)/50% co-
insurance (home
delivery)
Coverage is limited up to a 90-day supply
(retail) and up to 90-day supply (home
delivery)
Tier 2 – Non-preferred generic drugs
$15 copay (retail) /
$37 copay (home
delivery)
50% co-insurance
(retail)/50% co-
insurance (home
delivery)
Coverage is limited up to a 90-day supply
(retail) and up to 90-day supply (home
delivery)
Tier 3 - Preferred brand drugs
$45 copay (retail) /
$112 copay (home
delivery)
50% co-insurance
(retail)/50% co-
insurance (home
delivery)
Coverage is limited up to a 90-day supply
(retail) and up to a 90-day supply (home
delivery).
Tier 4 - Non-preferred brand drugs
50% co-insurance
(retail) / 50% co-
insurance (home
delivery)
50% co-insurance
(retail) / 50% co-
insurance (home
delivery)
Coverage is limited to a 90-day supply
(retail) and up to a 90-day supply (home
delivery)
Tier 5 - Specialty drugs
40% co-insurance
(retail) / 30% co-
insurance (home
delivery)
50% co-insurance
(retail)/50% co-
insurance (home
delivery)
(retail) and up to a 90-day supply (home
delivery). Pre-authorization required, call
1-800-Cigna24. Cost share increases if
no pre-authorization.
If you have outpatient
surgery
Facility fee (e.g., ambulatory surgery center) 20% co-insurance 50% co-insurance -----------------------None-------------------------
Physician/surgeon fees 20% co-insurance 50% co-insurance
Cigna24. Out-of-network cost share
increases if no pre-authorization.
If you need immediate
medical attention
Emergency room services 20% co-insurance 50% co-insurance
Emergency medical transportation 20% co-insurance 50% co-insurance
4 of 9
Cigna Health and Life Insurance Company: NC myCigna Health Flex 1250 Coverage Period: 1/1/14-12/31/14
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Family | Plan Type: OAP
Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary.
You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy.
Common
Medical Event Services You May Need
Your Cost If
You Use an
In-network
Provider
Your Cost If
You Use an
Out-of-network
Provider
Limitations & Exceptions
Urgent care $75 copay/visit 50% co-insurance Emergency medical conditions are
covered at the participating provider level.
If you have a hospital
stay
Facility fee (e.g., hospital room) 20% co-insurance 50% co-insurance
Cigna24. Out-of-network cost share
Physician/surgeon fee 20% co-insurance 50% co-insurance -----------------------None-------------------------
If you have mental
health, behavioral
health, or substance
abuse needs
Mental/Behavioral health outpatient services
20% co-insurance
50% co-insurance
Mental/Behavioral health inpatient services 20% co-insurance 50% co-insurance
Cigna24. Out-of-network cost share
Substance use disorder outpatient services
20% co-insurance
50% co-insurance
Substance use disorder inpatient services 20% co-insurance 50% co-insurance
Cigna24. Out-of-network cost share
If you are pregnant
Prenatal and postnatal care 20% co-insurance 50% co-insurance
Delivery and all inpatient services 20% co-insurance 50% co-insurance
Cigna24. Out-of-network cost share
5 of 9
Cigna Health and Life Insurance Company: NC myCigna Health Flex 1250 Coverage Period: 1/1/14-12/31/14
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Family | Plan Type: OAP
Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary.
You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy.
Common
Medical Event Services You May Need
Your Cost If
You Use an
In-network
Provider
Your Cost If
You Use an
Out-of-network
Provider
Limitations & Exceptions
If you need help
recovering or have
other special health
needs
Home health care 20% co-insurance 50% co-insurance
Cigna24. Out-of-network cost share
Rehabilitation services 20% co-insurance 50% co-insurance
chiropractic therapy is limited to 30 visits
Habilitation services 20% co-insurance 50% co-insurance
max
Skilled nursing care 20% co-insurance 50% co-insurance
max. Pre-authorization required, call 1-
800-Cigna24. Out-of-network cost share
Durable medical equipment 20% co-insurance 50% co-insurance -----------------------None-------------------------
Hospice service 20% co-insurance 50% co-insurance
Cigna24. Out-of-network cost share
If your child needs
dental or eye care
Eye exam
No charge
All except $45
Glasses No charge All except $30
Dental check-up Not Covered Not Covered
alone dental policy
6 of 9
Cigna Health and Life Insurance Company: NC myCigna Health Flex 1250 Coverage Period: 1/1/14-12/31/14
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Family | Plan Type: OAP
Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary.
You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy.
Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
• Acupuncture
• Bariatric surgery
• Cosmetic surgery
•
Dental care (Adult)
• Long-term care
• Non-emergency care when traveling outside the
U.S.
• Routine eye care (Adults)
• Weight loss programs
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)
• Dental care (child)
•
Eye exam (child)
• Hearing aids
•
Infertility treatment
• Private-duty nursing
•
Routine foot care
Your Rights to Continue Coverage:
Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are exceptions,
however, such as if:
• You commit fraud
• The insurer stops offering services in the State
• You move outside the coverage area
For more information on your rights to continue coverage, contact the insurer at 1-800-Cigna24.
You may also contact your state insurance department at 1-800-546-5664.
Your Grievance and Appeals Rights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance.
For questions about your rights, this notice, or assistance, you can contact: North Carolina Department of Insurance at 1-800-546-5664. Additionally, a consumer
assistance program can help you file your appeal, contact North Carolina Consumer Assistance program at 1-877-885-0231.
7 of 9
Cigna Health and Life Insurance Company: NC myCigna Health Flex 1250 Coverage Period: 1/1/14-12/31/14
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Family | Plan Type: OAP
Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary.
You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy.
Does this Coverage Provide Minimum Essential Coverage?
The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide
minimum essential coverage.
Does this Coverage Meet the Minimum Value Standard?
The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health
coverage does meet the minimum value standard for the benefits it provides.
Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-800-244-6224.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-244-6224.
Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-800-244-6224.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-244-6224.
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––
8 of 9
Cigna Health and Life Insurance Company: Covered NC myCigna Health Flex 1250 Coverage Period: 1/1/14-12/31/14
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Family | Plan Type: OAP
Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary.
You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy.
Having a baby
(normal delivery)
Managing type 2 diabetes
(routine maintenance of
a well-controlled condition)
About these Coverage
Examples:
These examples show how this plan might cover
medical care in given situations. Use these
examples to see, in general, how much financial
protection a sample patient might get if they are
covered under different plans.
Amount owed to providers: $7,540
Plan pays $4,980
Patient pays $2,560
Sample care costs:
Hospital charges (mother)
$2,700
Routine obstetric care
$2,100
Hospital charges (baby)
$900
Anesthesia
$900
Laboratory tests
$500
Prescriptions
$200
Radiology
$200
Vaccines, other preventive
$40
Total
$7,540
Patient pays:
Deductibles
$1,250
Copays
$60
Coinsurance
$1,220
Limits or exclusions
$30
Total
$2,560
Amount owed to providers: $5,400
Plan pays $3,390
Patient pays $2,010
Sample care costs:
Prescriptions
$2,900
Medical Equipment and Supplies
$1,300
Office Visits and Procedures
$700
Education
$300
Laboratory tests
$100
Vaccines, other preventive
$100
Total
$5,400
Patient pays:
Deductibles
$1,250
Copays
$430
Coinsurance
$10
Limits or exclusions
$320
Total
$2,010
This is
not a cost
estimator.
Don’t use these examples to
estimate your actual costs
under this plan. The actual
care you receive will be
different from these
examples, and the cost of
that care will also be
different.
See the next page for
important information about
these examples.
9 of 9
Cigna Health and Life Insurance Company: Covered NC myCigna Health Flex 1250 Coverage Period: 1/1/14-12/31/14
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Family | Plan Type: OAP
Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary.
You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy.
Questions and answers about the Coverage Examples:
What are some of the assumptions behind the
Coverage Examples?
• Costs don’t include premiums.
• Sample care costs are based on national
averages supplied by the U.S. Department
of Health and Human Services, and aren’t
specific to a particular geographic area or
health plan.
• The patient’s condition was not an excluded or
preexisting condition.
• All services and treatments started and
ended in the same coverage period.
• There are no other medical expenses for
any member covered under this plan.
• Out-of-pocket expenses are based only on
treating the condition in the example.
• The patient received all care from in-
network providers. If the patient had
received care from out-of-network
providers, costs would have been higher.
What does a Coverage Example show?
For each treatment situation, the Coverage
Example helps you see how deductibles, co-
payments, and co-insurance can add up. It also
helps you see what expenses might be left up to
you to pay because the service or treatment isn’t
covered or payment is limited.
Does the Coverage Example predict my own
care needs?
No. Treatments shown are just examples. The
care you would receive for this condition could
be different based on your doctor’s advice,
your age, how serious your condition is, and
many other factors.
Does the Coverage Example predict my future
expenses?
No. Coverage Examples are not cost
estimators. You can’t use the examples to
estimate costs for an actual condition. They
are for comparative purposes only. Your own
costs will be different depending on the care
you receive, the prices your providers
charge, and the reimbursement your health
plan allows.
Can I use Coverage Examples to compare
plans?
Yes. When you look at the Summary of
Benefits and Coverage for other plans, you’ll
find the same Coverage Examples. When you
compare plans, check the “Patient Pays” box
in each example. The smaller that number,
the more coverage the plan provides.
Are there other costs I should consider when
comparing plans?
Yes. An important cost is the premium you
pay. Generally, the lower your premium, the
more you’ll pay in out-of-pocket costs, such as
co-payments, deductibles, and co-
insurance. You should also consider
contributions to accounts such as health
savings accounts (HSAs), flexible spending
arrangements (FSAs) or health
reimbursement accounts (HRAs) that help you
pay out-of-pocket expenses.

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