1 2018 preMier PPO. Member Handbook State of Tennessee Group Insurance Program Offered by: cigna Health and Life Insurance Company, Connecticut General Life Insurance Company or their affiliates. 839769 j 10/17. 2018 preMier PPO. Important Notices Table of Contents This member handbook explains Welcome to many features of the preMier PPO Network 1. Plan Administration and Claims 1. health care option. It describes Adding 1. your benefits in general terms Important Contact Information .. 1. and is not intended to give all the Benefits at a 2. details of every benefit, limitation, Engaging in Your 4. or exclusion. The information Covered Medical 5. contained in this handbook is Excluded Services and 8. How the Plan 9. accurate at the time of printing.
2 Choice of 9. however, the Insurance Committees 9. may change the benefits at their Yearly 9. discretion, in which case you will be Maternity 9. given written notice of the change. Plan 9. Out-of-Pocket Maximums .. 10. The Benefits Administration Benefits: In-Network or Out-of-Network .. 10. website contains an electronic Maximum Allowable Charge 10. Convenient Care and Urgent 10. version of this handbook and Emergency 10. many other important publications Use of the Emergency 10. including a Summary of Benefits and Coverage (SBC) and a Plan Utilization Document. The Plan Document Prior is the official legal publication Advanced Radiological Durable Medical that defines eligibility, enrollment, Hearing Aids (for children under 18).
3 12. benefits and administrative rules Coordination of Benefits with Other Insurance of the state group insurance Claims program. Copies are available for Benefit Level your review from your agency Unique Care benefits coordinator or from Continuous Care Coverage for Second Surgical Opinion the State of Tennessee Benefits Case Administration website at Filing Out-of-State Out-of-Country Benefits Administration does Healthy Rewards Program *..15. not support any practice that cigna Healthy Babies ..15. excludes participation in programs Pharmacy or denies the benefits of such Behavioral Health and Substance Use programs on the basis of race, ParTNers for Health Wellness color, national origin, sex, age or Member Rights and disability in its health programs and Member activities.
4 If you have a complaint Confidentiality and regarding discrimination, please call Women's Health and Cancer Rights or Member Appeal 20. Administrative 20. Behavioral Health and Substance Use 20. Pharmacy 20. Medical Service 20. Q& Discrimination is Against the 2018 preMier PPO. Welcome to cigna cigna is the plan administrator for the preMier PPO plan statewide, and our business is your health. Your plan provides access to quality care, close to where you live and work. You have the freedom to choose your doctor either in or out of network and convenient, no referral access to specialists. We encourage you to use our online tools and resources to help you get the most out of your plan and to stay healthy. We stand ready to help, so just call the dedicated toll-free number on your cigna ID card if you have questions or concerns.
5 ID Cards You have ID cards for yourself and each of your covered dependents. Each covered person gets a card with their name on it. The cards show the name of your selected health option and the name of the network you chose. Review this information carefully and call if you have any questions. In-Network Preventive $0. PCP/OBGYN $25. Specialist $45. Hospital ER $150. Coinsurance 10%. preMier Deductible Applies See your actual 2018 ID card. See your actual 2018 ID card. The name of your plan will The name of the network for your appear here. plan will appear in this field. Note whether your card says LocalPlus (LP) or Open Access Plus (OAP). Be sure to schedule services with providers specific to your plan's network to receive maximum in network benefits | ii |.
6 2018 preMier PPO. Network Choices Important Contact Information cigna offers two network options for plan members. Please call member service for information about Your choice of network affects your monthly specific health care claims. Our representatives premium cost. are familiar with your specific coverage and The LocalPlus network has providers and are available to answer your questions. When contacting member service, you will be asked to facilities across Tennessee. There is no additional premium charge when you select this network. verify your identity and give information from your identification card. Open Access Plus is a large network with more doctors and facilities than the LocalPlus network. cigna A monthly surcharge applies if you select this cigna Member Services network.
7 If your usual plan network is LocalPlus, but you cigna Medical Claims are outside of the LocalPlus service area, you have PO Box 182223. access to cigna 's national Open Access Plus Chattanooga, TN 37422-7223. network of providers. Behavioral Health and Substance Use/. ParTNers Employee Assistance Program Plan Administration and Optum Health Claims Administration Benefits Administration, a division of the Pharmacy Department of Finance and Administration, is CVS/caremark the plan administrator and cigna is the claims administrator. This program is administered using ParTNers for Health Wellness Program the benefit structure established by the Insurance Committee that governs the plan. When claims are paid under this plan, they are paid from a fund consisting of your premiums and the employer's Website contributions (if applicable).
8 cigna is contracted by For general information about cigna , visit the state to process claims, establish and maintain and see what we are all about. adequate provider networks, and conduct utilization Once you enroll, is your personalized, management reviews. convenient and secure website. Claims paid in error for any reason may be recovered On you can: from the employee. Filing false or altered claim forms constitutes fraud and is subject to criminal Locate doctors, hospitals, and other prosecution. You may report possible fraud at any healthcare providers. time by contacting Benefits Administration. Verify plan details such as coverage, copays and deductibles. Adding dependents View and keep track of claims. If you want to add dependents to your coverage Find information and estimate costs for medical you must provide documentation verifying the procedures and treatments.
9 Dependent's eligibility to Benefits Administration. Learn about health conditions, treatments, etc. A list of acceptable documents is available from your agency benefits coordinator or the Benefits Administration website. |1|. 2018 preMier PPO. Benefits at a Glance TABLE 1: Services in this table ARE NOT subject to a deductible. Costs DO APPLY to the annual out of pocket maximums on TABLE 3. For further benefit details and plan limits, see sections on Covered Expenses and Excluded Services and Procedures. In-Network Out-of-Network1. PREVENTIVE CARE OFFICE VISITS. Well-baby, well-child visits as recommended by the Centers for Disease Control No Charge $45 copay and Prevention (CDC). Adult annual physical exam Annual well-woman exam Immunizations as recommended by CDC.
10 Annual hearing and non-refractive vision screening Screenings including colonoscopy, mammogram, and colorectal, Pap smears, labs, bone density scans, nutritional guidance, tobacco cessation counseling and other services as recommended by the US Preventive Services Task Force OUTPATIENT SERVICES. Primary Care Office Visit $25 copay $45 copay Family practice, general practice, internal medicine, OB/GYN and pediatrics Nurse practitioners, physician assistants and nurse midwives (licensed healthcare facility only) working under the supervision of a primary care provider Including surgery in office setting and initial maternity visit Specialist Office Visit $45 copay $70 copay Including surgery in office setting Behavioral Health and Substance Use Treatment2 $25 copay $45 copay (including telemental health).