Page 7 - KIPP NYC 2022 Benfits Summary

Medical Benefits
Medical and Prescription Drug Plans
KIPP NYC’s medical and prescription drug plan, insured by Cigna, offers access to a nationwide network of providers
through Cigna’s Open Access Plus (OAP) Network. The cost to the cost of coverage is deducted from your pay, each pay
Choice
You have the choice of seeing any provider without needing a referral for specialist visits. Claim forms are not required when utilizing network participating providers. Providers who participate in Cigna’s network accept negotiated rates which reduce your claim costs and out-of-pocket expenses. All plans offer “in-network” access and you have the option of selecting a plan with “out-of-network” benefits.
Cigna EPO Plan (OAPIN)
In-Network Only
If you elect the EPO Plan, you must exclusively utilize providers who participate in Cigna’s OAP Network. Benefits
are not available if you do not utilize a network provider.
Cigna PPO Plan (OAP)
In- and Out-of-Network Benefits
of this plan is shared by you and KIPP NYC. Your contribution period (24 times), on a pre-tax basis.
Prescription Drugs
Our plan will utilize the Cigna Standard 3-Tier Open Formulary. For information on quantity limits, step therapy and/or pre-certification requirements for certain prescription drugs, please contact Cigna by calling the member services number on the back of your Member ID card or visit the Cigna website at www.cigna.com or www.mycigna.com once your coverage is effective for a more customized experience.
Mail Order Program
The mail order program benefits employees who are on maintenance medications for chronic conditions such as diabetes, asthma and high blood pressure (or any medication you take on a regular basis). By ordering prescriptions by mail, you can receive a 90 day supply of prescriptions delivered directly to your home for 2 times the retail pharmacy copayment. You can order prescriptions for mail order online via www.cigna.com or www.mycigna.com.
The next page outlines specifics about our plan concerning in-network and out-of-network services. Please review and remember, you can find a more detailed benefits summary or locate participating providers online at www.cigna.com or www.mycigna.com.
How to Enroll
Visit the Benefits tab on UKG during your benefit enrollment window.
ID Cards
You should typically receive your ID card(s) within 10–15 business days after you make your benefit elections.
If you elect the PPO plan, you have the option to use providers who participate in the Cigna’s OAP Network or you may use a non-network provider. If you use a provider who is not in Cigna’s network, services rendered are subject to the plan’s annual deductible and coinsurance. An out- of-network provider may require payment at the time of service, in which case, you will need to file a claim to receive reimbursement up to the allowable charge for that service in your geographic area. The provider has the right to balance bill you for amounts in excess of the allowable charge.
2022 BENEFITS SUMMARY 7