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Summary Plan Description and Plan Document:Cigna Medical PlanHSA OptionsEFFECTIVE DATE: JANUARY 1, 20161
Table of ContentsINTRODUCTION. 1WHO TO CONTACT. 2ELIGIBILITY . 3Who Is Eligible . 3Who Can Be Covered . 3COSTS . 3Your Cost . 3Healthy Life Incentives . 3ENROLLMENT . 4When and How You Enroll . 4If You Are Newly Eligible. 4During the Annual Enrollment Period . 4If You Have a Life Status Change . 5Special Enrollment Rights . 5Enrolling Dependents . 5Enrolling Newborn Children . 6EVENTS AFFECTING YOUR PLAN COVERAGE, ELIGIBILITY OR COSTS . 6If You Have a Life Status Change . 6If The Plan Has a Change in Cost or Coverage. 7If You Are Enrolling a Dependent Who Has a Special Enrollment Right . 7If You Are Eligible for Coverage Under Another Medical Plan with a Different Plan Year . 7If You Are Subject to a Qualified Medical Child Support Order . 8If You Move . 8If Your Employment Status Changes. 8If You Become Eligible for Marketplace Coverage . 8If You Take a Leave of Absence . 8If You Take a Disability Leave . 9If You Take a Military Leave of Absence . 9If Your Cigna Employment Ends . 9If You Retire from Cigna . 10If You Die While Employed . 10If You Change Cigna Medical Plan Options . 10WHEN YOUR MEDICAL COVERAGE ENDS . 10Events That May Cause Cigna to Cancel Your Cigna Medical Plan Coverage . 11Rescissions. 11No Conversion Rights . 11OVERVIEW OF COVERAGE AND HEALTH SAVINGS ACCOUNT OPTIONS . 11In-Network and Out-of-Network Services Overview . 12Overview of Claim Processing . 12Deductibles, Coinsurance and Out-Of-Pocket Maximum . 12Deductibles . 12Coinsurance . 13Out-Of-Pocket Maximum . 13Unlimited Lifetime Maximum Benefit . 14Establishing a Health Savings Account . 14Special Requirements for Opening an Account . 14Federal HSA Contribution Limits . 15If You Are Age 55 or Older . 15i
Setting Up a Health Savings Account . 15Contributing to Your Health Savings Account . 16Your Contributions . 16Cigna’s Contributions . 16When Contributions Are Made . 16Managing Your Health Savings Account . 17Paying Qualified Medical Expenses from Your Health Savings Account . 17Earning Interest on Your HSA . 17Investing Your HSA . 17HSA Fees . 18If You Leave Cigna or Are No Longer Enrolled in the HSA Option . 18Closing Your Account . 18Tax Considerations . 18Filing Your Income Tax Return . 18COVERED EXPENSES . 18General Requirements for Covered Expenses . 19Preauthorization or Certification. 19Maximum Reimbursable Charges. 19Calculation of Covered Expenses . 20PHYSICIAN, HOSPITAL AND RELATED SERVICES . 20Preventive Care . 20Inpatient Hospital Services. 20Outpatient Hospital Services. 21Diagnostic Outpatient Testing . 21Radiation and Chemotherapy . 21Outpatient Surgery . 21Physician, Surgeon and Associated Medical Services . 22Anesthesia/X-Ray & Laboratory Services . 22Ambulance Service . 22Maternity Care . 22Newborn Care . 22Therapies for Participants Diagnosed with Autism Spectrum Disorder . 23Voluntary Family Planning . 23Infertility Services . 23Special Preauthorization Requirements . 24Lifetime Maximum Benefit for Infertility Diagnosis and Treatment . 24Skilled Nursing and Other Health Care Facility . 24Home Health Services . 24Hospice Care Services . 25Short-Term Rehabilitative Therapy and Chiropractic Services . 26Acupuncture Services . 26Internal Prosthetic Appliances. 27Breast Reconstruction and Breast Prostheses . 27Reconstructive Surgery . 27Transplant Services. 28Transplant Travel Services . 28External Prosthetic Appliances and Devices . 29Prostheses/Prosthetic Appliances and Devices . 29Orthoses and Orthotic Devices . 29Braces 30External Prosthetic Appliances-Wigs . 30ii
Hearing Aids . 30Durable Medical Equipment . 31Smoking Cessation Programs . 31Eye Care . 32Dental Expenses. 32Temporomandibular Disorders . 32Orthognathic Surgery . 32Gender Reassignment Surgery . 32Special Preauthorization Requirements . 33Clinical Trials . 33Telemedicine . 34Genetic Testing . 34Nutritional Evaluation . 35PRESCRIPTION DRUG BENEFITS . 35Covered Expenses . 36Dispensing Limits . 36Drug List . 36Prior Authorization. 37Pharmacy Program . 37Mail-Order Prescriptions Using Cigna Home Delivery Pharmacy . 37Preventive Generic Medication Paid in Full Through Cigna Home Delivery Pharmacy . 38Specialty Medication Through Cigna Home Delivery Pharmacy. 38Exclusive Home Delivery . 38Prescription Drug Exclusions. 38MENTAL HEALTH & SUBSTANCE ABUSE . 39The Employee Assistance Program (EAP) .
Jan 01, 2016 · Cigna Customer Service Center 1.888.99Cigna (1.888.992.4462) Email: Use the myCigna.com e-mail box P.O. Box 223684COBRA (health care coverage continuation) administration CONEXIS, a division of WageWorks Dallas, TX 75222- 3684. 1.888.678.4881 Health Savings Account Cigna Custom
