BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Standard COB Dependents Children birth to 26 Filing Limit 365 days Mailing Address & PPO Company Remit claims to: CIGNA Physicians & Hospitals PPO & NonPPO: Mail claims to Cigna, PO Box 188061 Chattanooga, TN 37422 8061. Electronic Payer ID 62308 Don t forget to get a copy of the Patient s ID Card for claim filing directions in order to expedite claims processing Pre Existing Does not apply Utilization Review: Cigna (888) 206 1019. Must precertify services listed 2 days prior to admission, Emergency admissions within 48 hours or 1 business day following admission Inpatient confinements Transplants Penalty: Additional $200 for covered expenses IN ANNUAL MAXIMUM BENEFIT HEALTH FUND Unlimited The first $500 of eligible in network expenses are paid at 100% no for each covered participant. Once the $500 is exhausted, the cost sharing listed below applies DEDUCTIBLE, PER CALENDAR YEAR Expenses applied toward the satisfaction of the PPO amount will be applied toward satisfaction of the Non PPO, and expenses applied toward the satisfaction of the Non PPO amount will be applied toward satisfaction of the PPO. Per Participant $1,000 $3,000 Per Family $2,000 $6,000 MAXIMUM OUT OF POCKET EXPENSES, PER CALENDAR Expenses applied toward the satisfaction of the PPO out of pocket amount will be applied toward satisfaction of the Non PPO out of pocket, and expenses applied toward the satisfaction of the Non PPO out of pocket amount will be applied toward satisfaction of the PPO out of pocket. Per Participant $1,000 $4,500 Per Family $2,000 $9,000 NOTE: The following charges do not apply toward the out of pocket expense amount and are never paid at 100%: Utilization Management Penalties Page 1 of 5
HEALTH BENEFITS: COPAYMENTS AND BENEFIT PERCENTAGES Accident Benefit Acupuncture Ambulance Bariatric Surgery Behavioral/Mental Health and Substance Use Disorders Inpatient Includes Residential Treatment Behavioral/Mental Health and Substance Use Disorders Outpatient Includes Partial Hospitalization Blood Chemotherapy & Radiation Therapy Chiropractic Treatment Convenience Care Clinic Dental Impacted Wisdom Teeth Diabetes Self management Training Diagnostic Testing (Advanced Imaging MRI, CAT, PET, nuclear stress tests, etc.) Diagnostic Testing (X ray, lab) Inpatient Diagnostic Testing (X ray, Blood work) Outpatient Hospital Diagnostic Testing (X ray, Blood work) Stand Alone Facility Diagnostic Testing (X ray, Blood work) Office Durable Medical Equipment Replacement allowed only after 5 years Emergency Room Extended Care/Skilled Nursing Facility (100 days calendar year maximum) Foot Conditions Physicians' services in connection with corns, calluses or toenails are excluded, unless the charges are for the partial or complete removal of the nail roots Routine foot care and foot orthotics are not covered Gastric Bypass Hearing Aid Hearing Exam Home Health Care (120 visits calendar year maximum) Hospice Care IN Non Surgical Treatment of the Spine Covered under Separate Dental plan Covered under Medical / Physician Services Surgeon for physician benefit (Facility charges will follow facility benefits). Bariatric Surgery 100%, no Bereavement Counseling by Hospice provider. For other bereavement counseling services refer to Behavioral/Mental Health and Substance Use Disorders Outpatient Page 2 of 5
Hospital / Facility Inpatient Room and Board is limited to the semiprivate room rate, or if the Hospital has private rooms only, the private room rate billed. ICU as billed. Hospital / Facility Outpatient Infertility/Sterility Covered up to diagnosis only Maternity Physician s Office Services Maternity related expenses for a dependent Child are covered Services not in the office Newborn Care (routine inpatient) Non Surgical Treatment of the Spine Limited to 60 visits per calendar year (OV & X ray not included in the maximum. Please refer to those benefit sections for applicable benefits) Obesity Coverage includes preventive counseling visits and/or risk factor reduction intervention; nutrition counseling; and healthy diet counseling visits provided in connection with Hyperlipidemia (high cholesterol) and other known risk factors for cardiovascular and diet related chronic disease. All other obesity related services are excluded Organ Transplants Donor charges are covered. plan document for limitations & exclusions Organ Transplant Travel & Accommodation Orthotics / Prosthetics Physician Services Inpatient Visits Physician Services Inpatient Surgeon Physician Services Outpatient Visits (services other than in a Physician s Office) Physician Services Outpatient Surgeon (services other than in a Physician s Office) Physician Services Office Visits Physician Services MDLIVE Call 877 953 4955, visit www.mdlive.com/gilsbar, or use the mobile app to receive general health care and pediatric care information for a member s condition. The MDLIVE program is available 24/7/365. See the Medical Benefits section for more details about this benefit. Physician Services In office Surgeon Prescription Drugs Inpatient Prescription Drugs Outpatient IN applicable service 100% no applicable service for benefits 100% no applicable service for benefits 100%, no Hospital / Facility Inpatient Prescription Drug Benefits schedule and section Page 3 of 5
Preventive Care Benefit Preventive care includes the following once annually: routine office visit and physical exam, prostatic/testicular exam, hearing screening and audiometric hearing exam (limited to 1 per 2 calendar years and hearing testing up to age 2), and vision exam (once every 2 calendar years including refraction and glaucoma test) Breast pumps are limited to one per calendar year Services are also covered as recommended by the United States Preventive Services Task Force (USPSTF) and immunizations will be covered as recommended by the Centers for Disease Control (CDC). All services are limited to no more than once annually or as recommended by the USPSTF. Private Duty Nursing (Limited to Inpatient only and 70 eight hour shifts per calendar year. Each period of private duty nursing of up to 8 hours will be deemed one private duty nursing shift) Rehabilitation Services (Cardiac Rehab, Occupational, Physical, Pulmonary, Speech and Vision Therapies) Provider must send letter of medical necessity and all applicable notes Cardiac rehab therapies limited to phase I & II Occupational, Physical and Speech Therapy limited to a combined visit maximum of 60 visits per calendar year Pulmonary rehab limited to 36 visits per calendar year IN 100%, no Vision Therapy Sleep Disorder Sleep Study Other eligible expenses Sterilization Vasectomy Female Sterilization Temporomandibular Joint Syndrome Urgent Care Facility (includes all covered charges billed by facility) Vision Exam Wig After Chemotherapy (Limited to one per covered person up to $300 lifetime) Preventive Care Preventive Care Preventive Care Page 4 of 5
PRESCRIPTION DRUG CARD INFORMATION Maxor Plus (800) 687 0707 RxBIN: 005377, RxPCN: 10000019, Rx Grp: S2855 UNIVERSITY OF THE INCARNATE WORD, S2855 Prescriptions that are purchased from a non participating pharmacy must be filed with the prescription drug company. Out of Network is 30% of submitted cost after applicable copay. OON mail order is not covered Prescriptions purchased from a participating pharmacy, but the drug card is not used must be filed with the prescription drug company. If a participant chooses a name brand drug when the Physician authorizes use of a generic drug the Participant must pay the difference between the actual cost of the generic and brand name in addition to the brand name copayment Prescription Drug Card Options Copayment Benefit Percentage Retail Pharmacy Option (30 day supply) Prescribed Preventive Medications and Contraceptives as recommended by the USPSTF. Copay follows tiers 100% Immunizations as recommended by the CDC Subject to existing brand costs if a generic both exists and is allowed by the physician. $ 0 100% Generic drug $10 100% Preferred Brand Name drug $25 100% Non Preferred Brand Name drug $50 100% Specialty Drugs Copay follows above tiers Mail Order Option (90 day supply) Prescribed Preventive Medications and Contraceptives as recommended by the USPSTF. Subject to existing brand costs if a generic both exists and is $15 100% allowed by the physician. Generic drug $15 100% Preferred Brand Name drug $37.50 100% Non Preferred Brand Name drug $75.00 100% Page 5 of 5