Transcription of SAMPLE Cigna Open Access Plus Plan
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SAMPLE Cigna Open Access Plus Plan
SAMPLE Cigna Open Access Plus Plan Important Information THIS IS A SAMPLE DOCUMENT. NO BENEFITS ARE GUARANTEED. NO COVERAGE REPRESENTATION IS CONSIDERED TO BE ACTUAL MEDICAL BENEFITS PROVIDED TO YOU BY Cigna . Table of Contents Important Information ..6 Special Plan Provisions ..8 Important Notices ..9 How To File Your Claim ..11 Eligibility - Effective Date ..11 Employee Insurance .. 11 Waiting Period .. 11 Dependent Insurance .. 12 Important Information About Your Medical Plan ..12 Open Access Plus Medical Benefits ..13 The Schedule .. 13 Certification Requirements - Out-of-Network .. 25 Prior Authorization/Pre-Authorized .. 25 Covered Expenses .. 26 Prescription Drug Benefits ..34 The Schedule .. 34 Covered Expenses .. 36 36 Your Payments .. 37 Exclusions .. 37 Reimbursement/Filing a Claim .. 37 Cigna Vision ..39 The Schedule .. 39 Covered Expenses .. 40 Expenses Not Covered .. 40 Exclusions, Expenses Not Covered and General Limitations.
how to select a primary care provider, and for a list of the participating primary care providers, visit www.mycigna.com or contact customer service at the phone number listed on the back of your ID card. For children, you may designate a pediatrician as the primary care provider. HC-NOT5 01-11 Important Information
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