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You can see the specialist you choose without permission from this plan.
your policy or plan document for additional information about excluded
Some of the services this plan doesn't cover are listed on page 5. See
Limitations & Exceptions -----------none----------- -----------none----------- Coverage for Chiropractic care is limited to 20 days annual max. -----------none----------- -----------none----------- $750 penalty for no precertification.
This plan may encourage you to use in-network providers by charging you lower deductibles, co-payments and co-insurance amounts.
Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Why this Matters: services. Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount of the service. For example, if the health plan's allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if you haven't The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount,
amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
In-Network Provider 20% co-insurance 20% co-insurance 20% co-insurance for chiropractor No charge 20% co-insurance 20% co-insurance If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
No. You don't need a referral to see a specialist.
Answers Yes. met your deductible. Services You May Need Primary care visit to treat an injury or illness Specialist visit Other practitioner office visit Preventive care/screening/ immunization Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy.
Important Questions Do I need a referral to see a specialist? Are there services this plan doesn't cover? Common Medical Event If you visit a health care provider's office or clinic If you have a test
15
You can see the specialist you choose without permission from this plan.
your policy or plan document for additional information about excluded
Some of the services this plan doesn't cover are listed on page 5. See
Limitations & Exceptions -----------none----------- -----------none----------- Coverage for Chiropractic care is limited to 20 days annual max. -----------none----------- -----------none----------- $750 penalty for no precertification.
This plan may encourage you to use in-network providers by charging you lower deductibles, co-payments and co-insurance amounts.
Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Why this Matters: services. Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount of the service. For example, if the health plan's allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if you haven't The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount,
amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
In-Network Provider 20% co-insurance 20% co-insurance 20% co-insurance for chiropractor No charge 20% co-insurance 20% co-insurance If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
No. You don't need a referral to see a specialist.
Answers Yes. met your deductible. Services You May Need Primary care visit to treat an injury or illness Specialist visit Other practitioner office visit Preventive care/screening/ immunization Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy.
Important Questions Do I need a referral to see a specialist? Are there services this plan doesn't cover? Common Medical Event If you visit a health care provider's office or clinic If you have a test
15
