What The CIGNA Plans Cover

The following is a summary of covered services, and the benefits that are paid for these services, under the CIGNA Medical Plans. Keep in mind that these expenses incurred for listed services must be recommended by a physician and must be considered essential for the necessary care and treatment of an injury or a sickness (unless the covered service listed is for preventive care). 

This information is divided into the following major categories...

  • At The Doctor's Office

  • At The Hospital

  • Surgery

  • Maternity Services

  • Mental Health/Substance Abuse Treatment

  • Other Frequently Utilized Services

Additional details on these and other covered services, is provided under Description of Covered Services; details on the Plans' prescription drug benefits are provided under Prescription Drug Benefits Under The CIGNA Plans.

Note that the benefit descriptions provided below are summaries; they do not reflect all limitations or restrictions. For complete details, refer to the official plan document or booklet (available from your local Human Resources representative), or contact CIGNA directly at the number shown on your medical ID card.

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At The Doctor's Office

Office Visits

  • CIGNA Low Option PPO OA+ Plan

    • Network—Plan pays 80% after deductible.

    • Non-Network—Plan pays 50% after deductible.

  • CIGNA High Option PPO OA+ Plan

    • Network—Plan pays 100% after a $20 copayment and a $35 copayment when visiting a specialist.

    • Non-Network—Plan pays 70% after deductible.

  • CIGNA Network HMO Plan—Plan pays 100% after a $20 copayment when visiting your PCP and a $30 copayment when visiting a specialist.

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Preventive Care

  • CIGNA Low Option PPO OA+ Plan

    • Network—Plan pays 100%, deductible waived; benefit is limited to one exam every 12 months.

    • Non-Network—Not covered.

  • CIGNA High Option PPO OA+ Plan

    • Network—Plan pays 100%, deductible waived; benefit is limited to one exam every 12 months.

    • Non-Network—not covered.

  • CIGNA Network HMO Plan—Plan pays 100%, no copayment; benefit is limited to one exam per calendar year.

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Well Child Care

  • CIGNA Low Option PPO OA+ Plan

    • Network-Plan pays 100%, deductible waived.

    • Non-Network—Not covered.

  • CIGNA High Option PPO OA+ Plan

    • Network—Plan pays 100%, deductible waived, for children through age 2.

    • Non-Network—Not covered.

  • CIGNA Network HMO Plan—Plan pays 100%, no copayment.

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At The Hospital

Note: Failure to obtain utilization review for any hospitalization services that require it will result in an additional fee (as outlined previously under Utilization Review); also, benefits are paid only if the stay and services provided are considered medically necessary.

Emergency Room

  • CIGNA Low Option PPO OA+ Plan

    • Network or Non-Network—Plan pays 80% after deductible.

  • CIGNA High Option PPO OA+ Plan

    • Network or Non-Network—Plan pays 90% after deductible.

  • CIGNA Network HMO Plan—Plan pays 100% after a $75 copayment. The copayment is waived if the patient is admitted to the hospital following the emergency room visit.

Note that under the Plans, no benefits are paid for non-emergency care obtained in an emergency room.

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Semi-Private Room And Board

  • CIGNA Low Option PPO OA+ Plan

    • Network—Plan pays 80% after deductible.

    • Non-Network—Plan pays 50% after plan deductible and $1,000 hospital confinement deductible.

  • CIGNA High Option PPO OA+ Plan   

    • Network—Plan pays 90% after deductible.

    • Non-Network—Plan pays 70% after plan deductible and $400 hospital confinement deductible.

  • CIGNA Network HMO Plan—Plan pays 100% after a $300 admission copayment.

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Inpatient X-ray And Lab Services

  • CIGNA Low Option PPO OA+ Plan

    • Network—Plan pays 80% after deductible.

    • Non-Network—Plan pays 50% after deductible.

  • CIGNA High Option PPO OA+ Plan

    • Network—Plan pays 90% after deductible.

    • Non-Network—Plan pays 70% after deductible.

  • CIGNA Network HMO Plan—Plan pays 100%.

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Surgery

Outpatient

  • CIGNA Low Option PPO OA+ Plan

    • Network—Plan pays 80% after deductible.

    • Non-Network—Plan pays 50% after deductible.

  • CIGNA High Option PPO OA+ Plan

    • Network—Plan pays 90% after deductible.

    • Non-Network—Plan pays 70% after deductible.

  • CIGNA Network HMO Plan-Plan pays 100% after a $150 facility copayment ($20 if performed in PCP office; $30 for specialist).

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Inpatient

  • CIGNA Low Option PPO OA+ Plan

    • Network—Plan pays 80% after deductible.

    • Non-Network—Plan pays 50% after plan deductible and $1,000 hospital confinement deductible.

  • CIGNA High Option PPO OA+ Plan

    • Network—Plan pays 90% after deductible.

    • Non-Network—Plan pays 70% after deductible.

  • CIGNA Network HMO Plan—Plan pays 100% after a $300 per admission copayment.

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Maternity Services

For important details regarding these benefits and your rights under federal law, see Maternity Services.

Office Visits

  • CIGNA Low Option PPO OA+ Plan

    • Network—Plan pays 80% after deductible.

    • Non-Network—Plan pays 50% after deductible.

  • CIGNA High Option PPO OA+ Plan

    • Network—Plan pays 100% after a $20 copayment ($35 copayment for specialist) for the initial visit, 90% after deductible thereafter.

    • Non-Network—Plan pays 70% after deductible.

  • CIGNA Network HMO Plan—Plan pays 100% after a $20 copayment ($30 copayment for specialist) for the initial visit, 100% thereafter.

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Hospital Services

  • CIGNA Low Option PPO OA+ Plan

    • Network—Plan pays 80% after deductible.

    • Non-Network—Plan pays 50% after plan deductible and $1,000 hospital confinement deductible.

  • CIGNA High Option PPO OA+ Plan

    • Network—Plan pays 90% after deductible.

    • hospital Non-Network—Plan pays 70% after plan deductible and $400 confinement deductible.

  • CIGNA Network HMO Plan—Plan pays 100% after a $300 per admission copayment.

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Mental Health/Substance Abuse Treatment

Includes treatment for mental and nervous disorders, as well as alcoholism and drug abuse, up to the maximum benefits. Treatment must be provided by a licensed psychiatrist (M.D.) or licensed psychologist.

Inpatient

  • CIGNA Low Option PPO OA+ Plan

    • Network—Plan pays 80% after deductible.

    • Non-Network—Plan pays 50% after plan deductible and $1,000 admission deductible.

  • CIGNA High Option PPO OA+ Plan

    • Network—Plan pays 90% after deductible.

    • Non-Network—Plan pays 70% after plan deductible and $400 admission deductible.

  • CIGNA Network HMO Plan—Plan pays 100% after a $300 per admission copayment.

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Outpatient

  • CIGNA Low Option PPO OA+ Plan

    • Network—Plan pays 80% after deductible.

    • Non-Network—Plan pays 50% after deductible.

  • CIGNA High Option PPO OA+ Plan

    • Network—Plan pays 100% after a $35 copayment.

    • Non-Network—Plan pays 70% after deductible.

  • CIGNA Network HMO Plan—Plan pays 100% after a $30 copayment.

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Other Frequently Utilized Services

Outpatient X-ray & Lab Services

  • CIGNA Low Option PPO OA+ Plan

    • Network—Plan pays 80% after deductible.

    • Non-Network—Plan pays 50% after deductible.

  • CIGNA High Option PPO OA+ Plan

    • Network—Plan pays 90% after deductible.

    • Non-Network—Plan pays 70% after deductible.

  • CIGNA Network HMO Plan—Plan pays 100%.

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Skilled Nursing Facility

Note: Under the Plans, benefits are limited to 120 days per calendar year.

  • CIGNA Low Option PPO OA+ Plan

    • Network—Plan pays 80% after deductible.

    • Non-Network—Plan pays 50% after deductible.

  • CIGNA High Option PPO OA+ Plan

    • Network—Plan pays 90% after deductible.

    • Non-Network—Plan pays 70% after deductible.

  • CIGNA Network HMO Plan—Plan pays 100%.

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Home Health Care

  • CIGNA Low Option PPO OA+ Plan

    • Network—Plan pays 80% after deductible.

    • Non-Network—Plan pays 50% after deductible.

  • CIGNA High Option PPO OA+ Plan

    • Network—Plan pays 90% after deductible.

    • Non-Network—Plan pays 70% after deductible.

  • CIGNA Network HMO Plan—Plan pays 100%.

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Hearing Exams/Hearing Aids

Note: Under the Plans, benefits are limited to $1,500 every 36 months; repair and replacement not covered.

  • CIGNA Low Option PPO OA+ Plan

    • Network—Plan pays 80% after deductible.

    • Non-Network—Plan pays 50% after deductible.

  • CIGNA High Option PPO OA+ Plan

    • Network - Plan pays 90% after deductible.

    • Non-Network - Plan pays 70% after deductible.

  • CIGNA Network HMO Plan—Plan pays 100%.

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Durable Medical Equipment

  • CIGNA Low Option PPO OA+ Plan

    • Network—Plan pays 80% after deductible.

    • Non-Network—Plan pays 50% after deductible.

  • CIGNA High Option PPO OA+ Plan

    • Network—Plan pays 90% after deductible.

    • Non-Network—Plan pays 70% after deductible.

  • CIGNA Network HMO Plan—Plan pays 100%.

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Urgent Care Services

  • CIGNA Low Option PPO OA+ Plan

    • Network or Non-Network—Plan pays 80% after deductible.

  • CIGNA High Option PPO OA+ Plan

    • Network or Non-Network—Plan pays 90% after deductible.

  • CIGNA Network HMO Plan—Plan pays 100% after a $50 copayment. The copayment is waived if the patient is admitted to the hospital following urgent care treatment.

Note that under the Plans, no benefits are paid for non-emergency care obtained in an urgent care center.

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Prescription Drug Benefits Under The CIGNA Plans

The PPO and HMO Plans pay benefits for prescription drugs that have been ordered as a result of an accidental injury, illness, or pregnancy. You have two ways to fill your prescriptions: at a retail pharmacy (for medications up to a 30-day supply) and through the mail (for medications up to a 90-day supply).

Obtaining Your Retail Prescription Drugs

In general, you must obtain your prescription drugs at a participating pharmacy. If you are enrolled in the CIGNA High Option PPO OA+ Plan, you may obtain your prescriptions from a non-participating retail pharmacy, but you will pay more at non-participating pharmacies. At the time you obtain your prescription at a participating pharmacy, you need only present your medical plan ID card and pay the required copayment. You can receive up to a 30-day supply of medication when you fill your prescriptions through a retail pharmacy.

  • CIGNA Low Option PPO OA+ Plan (participating pharmacies only): Plan pays 100% after $10 copayment for generic drugs, 70% for preferred brand name drugs, and 45% for non-preferred brand name drugs. For preferred brand and non-preferred brand, after you pay a total of $500 in a year, the plan pays 100%.

  • CIGNA High Option PPO OA+ Plan:

    • Participating Pharmacy—Plan pays 100% after $10 copayment for generic drugs, $20 copayment for preferred brand name drugs and $40 copayment for non-preferred brand name drugs.

    • Non-Participating pharmacy—Plan pays 60%. If you obtain your prescription from a non-participating pharmacy, you will need to pay for the prescription in full and then file a claim for benefits. To file a claim for drug benefits, obtain the appropriate claim form from your local Human Resources representative (this form may also be available online via the Company intranet). The form includes instructions and information as to where the claim should be sent.

  • CIGNA Network HMO Plan (participating pharmacies only): Plan pays 100% after $10 copayment for generic drugs, $20 copayment for preferred brand name drugs and $40 copayment for non-preferred brand name drugs.

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Using The Mail-Order Program

You may also obtain certain prescription drugs (such as regular maintenance medications) through a mail-order program and receive a 90-day supply.

  • CIGNA Low Option PPO OA+ Plan (participating pharmacies only): Plan pays 100% after a $20 copayment for generic drugs; plan pays 70% for preferred brand name drugs; plan pays 45% for non-preferred brand name drugs. For preferred brand and non-preferred brand, after you pay a total of $500 in a year, the plan pays 100%.

  • CIGNA High Option PPO OA+ Plan (participating pharmacies only): Plan pays 100% after a $20 copayment for generic drugs, $40 copayment for preferred brand name drugs and $80 copayment for non-preferred brand name drugs.

  • CIGNA Network HMO Plan (participating pharmacies only): Plan pays 100% after a $20 copayment for generic drugs, $40 copayment for preferred brand name drugs and $80 copayment for non-preferred brand name drugs.

For additional information about obtaining prescription drugs through the mail-order program, contact your local Human Resources representative.

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What The Prescription Drug Benefit Program Does Not Cover

The following are not covered through the CIGNA prescription drug benefit program...

  • Non-legend drugs (over-the-counter).

  • Any drug for which payment cannot lawfully be made.

  • Charges that the person is not legally required to pay.

  • Charges that would not have been made if the person were not covered by these benefits.

  • Experimental drugs or drugs labeled: "Caution—limited by federal law to investigational use."

  • Drugs that are not considered essential for the necessary care and treatment of an injury or sickness, as determined by the Plan.

  • Drugs obtained from a non-participating mail-order pharmacy.

  • Any prescription filled exceeding the number specified by the physician or dispensed more than one year from the date of the physician's order.

  • Any prescription ordered through a retail pharmacy that is more than a 30-day supply.

  • Any prescription ordered through the mail-order program that is more than a 90-day supply.

  • Prescriptions for indications not approved by the Food and Drug Administration.

  • A brand name drug to the extent that the charge for the brand name drug exceeds the charge for a comparable FDA "A-rated" generic, where available (this limitation does not apply if the physician requests the brand name drug and specifies "Dispense as Written" on the prescription order).

  • Immunization agents, biological sera, blood, or blood plasma.

  • Therapeutic devices or appliances, including hypodermic needles, syringes, support garments and other non-medicinal substances, and excluding insulin syringes.

  • Drugs used for cosmetic purposes.

  • Tretinoin for individuals age 36 and over.

  • Administration of any drug (administration may be covered under the medical benefits portion of the plan).

  • Medication that is taken or administered, in whole or in part, at the place where it is dispensed or while the person is confined in an institution which operates, or allows to be operated on its premises, a facility for dispensing pharmaceuticals (this may be covered under the medical benefits portion of the plan).

  • Prescriptions for which payment is made or available through any Workers' Compensation or similar law or any public program other than Medicaid.

  • Growth hormones and anabolic steroids.

  • Nutritional or dietary supplements, anti-obesity drugs or anorexiants (appetite suppressant drugs).

  • Prescription vitamins other than prenatal vitamins.

  • Oral fertility drugs.

  • Smoking cessation products.

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