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.

office or a utilization review program (see the PAC/CSR section of your certificate) may refer an individual for Case Management. The Review Organization assesses each case to determine whether Case Management is appropriate. You or your Dependent is contacted by an assigned Case Manager who explains in detail how the program works.

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  Programs, Management, Cigna

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