Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
Coverage Period: 01/01/2024 - 12/31/2024
Cigna Health and Life Insurance Co.: Open Access Plus Coverage for: Individual/Individual + Family | Plan Type: OAP The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go online at www.cigna.com/sp. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 1-866-494-2111 to request a copy. Important Questions Answers Why This Matters:
Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care- benefits/.
For in-network providers: $500/individual or $1,500/family For out-of-network providers: $1,000/individual or $3,000/family Yes. In-network preventive care & immunizations, out-of- network immunizations through age 5, office visits, diagnostic test, prescription drugs, emergency room visits, urgent care facility visits.
What is the overall deductible?
Are there services covered before you meet your deductible?
Are there other deductibles for specific services?
No.
You don't have to meet deductibles for specific services.
For in-network providers: $3,000/individual or $9,000/family For out-of-network providers: $28,000/individual or $56,000/family Combined medical/behavioral and pharmacy out-of- pocket limit Penalties for failure to obtain pre-authorization for services, premiums, balance-billing charges, and health care this plan doesn’t cover.
The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.
What is the out-of-pocket limit for this plan?
What is not included in the out-of-pocket limit?
Even though you pay these expenses, they don't count toward the out-of- pocket limit.
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Important Questions
Answers
Why This Matters:
This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
Will you pay less if you use a network provider?
Yes. See www.cigna.com or call 1-866-494-2111 for a list of network providers.
Do you need a referral to see a specialist?
No.
You can see the specialist you choose without a referral.
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. What You Will Pay Common Medical Event Services You May Need In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most)
Limitations, Exceptions, & Other Important Information
Primary care visit to treat an injury or illness
$30 copay/visit Deductible does not apply $60 copay/visit Deductible does not apply
40% coinsurance
None
Specialist visit
40% coinsurance
None None None
No charge/visit**
40% coinsurance/visit 40% coinsurance/other services No charge/immunizations**
No charge/other services**
If you visit a health care provider's office or clinic
No charge/immunizations** No charge/immunizations** **Deductible does not apply
Coverage birth through age 5 Coverage age 6 and older
40% coinsurance/ immunizations
Preventive care/ screening/immunization
**Deductible does not apply
You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.
Diagnostic test (x-ray, blood work)
No charge Deductible does not apply
If you have a test
40% coinsurance
None
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What You Will Pay
Common Medical Event
Limitations, Exceptions, & Other Important Information $250 penalty for no out-of-network precertification. Coverage is limited up to a 90-day supply (retail and home delivery); up to a 30-day supply (retail and home delivery) for Specialty drugs. Certain limitations may apply, including, for example: prior authorization, step therapy, quantity limits. For drugs in the Cigna Patient Assurance Program you may pay less than the noted retail or home delivery cost share amounts. In-network Federally required preventive drugs will be provided at no charge. $250 penalty for no out-of-network precertification. $250 penalty for no out-of-network precertification. Per visit copay is waived if admitted. Out-of-network services are paid at the in-network cost share. Out-of-network air ambulance services are paid at the in-network cost share and deductible. Per visit copay is waived if admitted.
Services You May Need
In-Network Provider (You will pay the least) 20% coinsurance at an outpatient facility 20% coinsurance in the office $10 copay/prescription (retail 30 days), $30 copay/prescription (retail & home delivery 90 days) Deductible does not apply $50 copay/prescription (retail 30 days), $150 copay/prescription (retail & home delivery 90 days) Deductible does not apply $100 copay/prescription (retail 30 days), $300 copay/prescription (retail & home delivery 90 days) Deductible does not apply $250 copay/prescription (retail & home delivery 30 days) Deductible does not apply
Out-of-Network Provider (You will pay the most) 40% coinsurance at an outpatient facility 40% coinsurance in the office 50% coinsurance/prescription (retail and home delivery) Deductible does not apply
Imaging (CT/PET scans, MRIs)
Generic drugs (Tier 1)
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.cigna.com
50% coinsurance/prescription (retail and home delivery) Deductible does not apply
Preferred brand drugs (Tier 2)
50% coinsurance/prescription (retail and home delivery) Deductible does not apply 50% coinsurance/prescription (retail and home delivery) Deductible does not apply
Non-preferred brand drugs (Tier 3)
Specialty drugs (Tier 4)
Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees
20% coinsurance
40% coinsurance
If you have outpatient surgery
20% coinsurance
40% coinsurance
$500 copay/visit, plus 20% coinsurance Deductible does not apply
$500 copay/visit, plus 20% coinsurance Deductible does not apply
Emergency room care
If you need immediate medical attention
Emergency medical transportation
20% coinsurance
20% coinsurance
$75 copay/visit Deductible does not apply
$75 copay/visit Deductible does not apply
Urgent care
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What You Will Pay
Common Medical Event
Limitations, Exceptions, & Other Important Information $250 penalty for no out-of-network precertification. $250 penalty for no out-of-network precertification. $250 penalty if no precert of out-of- network non-routine services (i.e., partial hospitalization, etc.). Includes medical services for MH/SA diagnoses. $250 penalty for no out-of-network precertification. Includes medical services for MH/SA diagnoses. Primary Care or Specialist benefit levels apply for initial visit to confirm pregnancy. Cost sharing does not apply for preventive services. Depending on the type of services, a copayment, coinsurance or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). $250 penalty for no out-of-network precertification. Coverage is limited to 60 visits annual max. (The limit is not applicable to mental health and substance use disorder conditions.)
Services You May Need
In-Network Provider (You will pay the least)
Out-of-Network Provider (You will pay the most)
Facility fee (e.g., hospital room) Physician/surgeon fees
20% coinsurance
40% coinsurance
If you have a hospital stay
20% coinsurance
40% coinsurance
$60 copay/office visit** 20% coinsurance/all other services **Deductible does not apply
40% coinsurance/office visit 40% coinsurance/all other services
Outpatient services
If you need mental health, behavioral health, or substance abuse services
Inpatient services
20% coinsurance
40% coinsurance
Office visits
20% coinsurance 20% coinsurance
40% coinsurance 40% coinsurance
Childbirth/delivery professional services
If you are pregnant
Childbirth/delivery facility services
20% coinsurance
40% coinsurance
If you need help recovering or have other special health needs
Home health care
20% coinsurance
40% coinsurance
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What You Will Pay
Common Medical Event
Limitations, Exceptions, & Other Important Information $250 penalty for failure to precertify out-of-network speech therapy. Coverage is limited to an annual max of 35 visits for Physical therapy, Speech, Hearing & Occupational therapy and 35 visits annual max for Chiropractic care services. Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies. $250 penalty for failure to precertify out-of-network speech therapy. Services are covered when Medically Necessary to treat a mental health condition (e.g. autism) or a congenital abnormality. Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies. $250 penalty for no out-of-network precertification. Coverage is limited to 30 days annual max. $250 penalty for no out-of-network precertification. $250 penalty for no out-of-network precertification.
Services You May Need
In-Network Provider (You will pay the least)
Out-of-Network Provider (You will pay the most)
$60 copay/visit for Physical, Speech, Hearing & Occupational therapy** $60 copay/visit for Chiropractic care** **Deductible does not apply
40% coinsurance/visit for Physical, Speech, Hearing & Occupational therapy 40% coinsurance/visit for Chiropractic care
Rehabilitation services
$60 copay/visit for Physical, Speech, Hearing & Occupational therapy** **Deductible does not apply
40% coinsurance/visit for Physical, Speech, Hearing & Occupational therapy
Habilitation services
Skilled nursing care
20% coinsurance
40% coinsurance
Durable medical equipment 20% coinsurance
40% coinsurance
20% coinsurance/inpatient services 20% coinsurance/outpatient services
40% coinsurance/inpatient services 40% coinsurance/outpatient services
Hospice services
Children's eye exam Children's glasses
Not covered Not covered
Not covered Not covered
None None
If your child needs dental or eye care
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What You Will Pay
Common Medical Event
Limitations, Exceptions, & Other Important Information
Services You May Need
In-Network Provider (You will pay the least)
Out-of-Network Provider (You will pay the most)
Children's dental check-up Not covered
Not covered
None
Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Acupuncture
Infertility treatment Long-term care Non-emergency care when traveling outside of the U.S. Private-duty nursing
Routine eye care (Adult) Routine eye care (Children) Routine foot care Weight loss programs
Bariatric surgery Cosmetic surgery Dental care (Adult) Dental care (Children)
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Chiropractic care (35 visits) Hearing aids (2 (one per ear) devices per 36 months, through age 18) Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Texas Department of Insurance at 1- 800-578-4677 and Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Other coverage options may be available to you, too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Cigna Customer service at 1-866- 494-2111. You may also contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform or Texas Department of Insurance at 1-800-578-4677. Additionally, a consumer assistance program can help you file your appeal. Contact: Texas Consumer Health Assistance Program at (800) 252-3439. Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
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Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-866-494-2111. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-866-494-2111. Chinese ( 中文 ): 如果需要中文的帮助，请拨打这个号码 1-866-494-2111. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-866-494-2111.
To see examples of how this plan might cover costs for a sample medical situation, see the next section.
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About these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing Joe's type 2 Diabetes (a year of routine in-network care of a well- controlled condition) Mia's Simple Fracture (in-network emergency room visit and follow up care)
■ The plan's overall deductible ■ Specialist copayment ■ Hospital (facility) coinsurance
$500 $60 20% 20%
■ The plan's overall deductible ■ Specialist copayment ■ Hospital (facility) coinsurance
$500 $60 20% 20%
■ The plan's overall deductible ■ Specialist copayment ■ Hospital (facility) coinsurance
$500 $60 20% 20%
■ Other coinsurance
■ Other coinsurance
■ Other coinsurance
This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)
This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)
This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)
Total Example Cost
$12,700
Total Example Cost
$5,600
Total Example Cost
$2,800
In this example, Peg would pay: Cost Sharing Deductibles
In this example, Joe would pay: Cost Sharing Deductibles
In this example, Mia would pay: Cost Sharing Deductibles
$500 $40
$0
$500 $800 $200
Copayments Coinsurance
Copayments Coinsurance
$700
Copayments Coinsurance
$2,100
$0
What isn't covered
What isn't covered
What isn't covered
Limits or exclusions
$20
Limits or exclusions
$40 $740
Limits or exclusions
$0
The total Peg would pay is
The total Joe would pay is
The total Mia would pay is
$2,660
$1,500
The plan would be responsible for the other costs of these EXAMPLE covered services.
Plan Name: OAP Buy Up Ben Ver: 29 Plan ID: 27123025 HP-POL/HP-APP 9/23/12
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Medical coverage DISCRIMINATION IS AGAINST THE LAW
a grievance by sending an email to ACAGrievance@Cigna.com or by writing to the following address: Cigna Nondiscrimination Complaint Coordinator PO Box 188016 Chattanooga, TN 37422 If you need assistance filing a written grievance, please call the number on the back of your ID card or send an email to ACAGrievance@Cigna.com. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, DC 20201 1.800.368.1019, 800.537.7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Cigna complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Cigna does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Cigna: • Provides free aids and services to people with disabilities to communicate effectively with us, such as: – Qualified sign language interpreters – Written information in other formats (large print, audio, accessible electronic formats, other formats) • Provides free language services to people whose primary language is not English, such as: – Qualified interpreters – Information written in other languages If you need these services, contact customer service at the toll-free number shown on your ID card, and ask a Customer Service Associate for assistance. If you believe that Cigna has failed to provide theseservices or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Evernorth Care Solutions, Inc., Evernorth Behavioral Health, Inc., Cigna Health Management, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. ATTENTION: If you speak languages other than English, language assistance services, free of charge are available to you. For current Cigna customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711). ATENCIÓN: Si usted habla un idioma que no sea inglés, tiene a su disposición servicios gratuitos de asistencia lingüística. Si es un cliente actual de Cigna, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY deben llamar al 711). 896375b 05/21 © 2021 Cigna.
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