RI 73-028
Serving: Maricopa County and Apache Junction
Enrollment in this
Plan is limited; see page 6 for requirements.
http:// www. CIGNA. com/ healthcare
This plan has commendable accreditation
from the NCQA. See the 2001
Guide
for more information on NCQA.
For changes
in benefits
see page
7.
CIGNA HealthCare of Arizona, Inc.
HealthCare of Arizona 1
1 Page 2 3
2 2001 CIGNA HealthCare of Arizona, Inc.
Table of Contents
Table of Contents
Introduction
..................................................................................................................................................................
4
Plain Language
.............................................................................................................................................................
4
Section 1. Facts about this HMO Plan
......................................................................................................................
5
How we pay providers
.............................................................................................................................
5
Who provides my health care?
.................................................................................................................
6
Patients' Bill of Rights
.............................................................................................................................
6
Service Area
............................................................................................................................................
6
Section 2. How we change for 2001.
........................................................................................................................
7
Program-wide changes
............................................................................................................................
7
Changes to this Plan
................................................................................................................................
7
Section 3. How you get care
.....................................................................................................................................
8
Identification cards
..................................................................................................................................
8
Where you get covered care
.....................................................................................................................
8
° Plan providers
....................................................................................................................................
8
° Plan facilities
.....................................................................................................................................
8
What you must do to get covered care
......................................................................................................
8
° Primary care
......................................................................................................................................
9
° Specialty care
....................................................................................................................................
9
° Hospital care
......................................................................................................................................
10
Circumstances beyond our control
...........................................................................................................
10
Services requiring our prior approval
.......................................................................................................
10
Section 4. Your costs for covered services
................................................................................................................
11
° Copayments
.......................................................................................................................................
11
° Deductible
.........................................................................................................................................
11
° Coinsurance
.......................................................................................................................................
11
Your out-of-pocket maximum for copayments
.........................................................................................
11
Section 5. Benefits
...................................................................................................................................................
12
Overview
.................................................................................................................................................
12
(a) Medical services and supplies provided by physicians and other health
care professionals ................. 13
(b) Surgical and anesthesia services
provided by physicians and other health care professionals ............. 19
(c) Services provided by a hospital or other facility, and ambulance
services ........................................... 22
(d) Emergency
services/ accidents
...........................................................................................................
24
(e) Mental health and substance abuse benefits
.......................................................................................
26
(f) Prescription drug benefits
...................................................................................................................
28
(g) Special features
.................................................................................................................................
30
(h) Dental benefits
..................................................................................................................................
31
(i) Non-FEHB benefits available to Plan members
.................................................................................
32 2
2 Page 3 4
3 2001 CIGNA HealthCare of Arizona, Inc.
Table of Contents (continued)
Table of
Contents
Section 6. General exclusions Ñ things we don't cover
...........................................................................................
33
Section 7. Filing a claim for covered services
..........................................................................................................
34
Section 8. The disputed claims process
....................................................................................................................
35
Section 9. Coordinating benefits with other coverage
..............................................................................................
37
When you have . . .
° Other health coverage
.......................................................................................................................
37
° Original Medicare
............................................................................................................................
37
° Medicare managed care plan
............................................................................................................
39
TRICARE/ Workers' Compensation/ Medicaid
........................................................................................
39
Other Government Agencies
...................................................................................................................
40
When others are responsible for injuries
.................................................................................................
40
Section 10. Definitions of terms we use in this brochure
............................................................................................
41
Section 11. FEHB facts
.............................................................................................................................................
42
Coverage information
............................................................................................................................
42
° No pre-existing condition limitation
.................................................................................................
42
° Where you get information about enrolling in the FEHB Program
.................................................... 42
° Types of
coverage available for you and your family
........................................................................ 42
° When benefits and premiums start
....................................................................................................
42
° Your medical and claims records are confidential
............................................................................. 42
° When you retire
................................................................................................................................
43
When you lose benefits
...........................................................................................................................
43
° When FEHB coverage ends
..............................................................................................................
43
° Spouse equity coverage
....................................................................................................................
43
° Temporary Continuation of Coverage (TCC)
....................................................................................
43
° Converting to individual coverage
....................................................................................................
43
° Getting a Certificate of Group Health Plan Coverage
........................................................................ 44
Inspector General Advisory
....................................................................................................................
44
Index
............................................................................................................................................................................
45
Summary of benefits
.....................................................................................................................................................
47
Rates
................................................................................................................................................................
Back cover 3
3 Page
4 5
4 2001 CIGNA HealthCare of Arizona,
Inc. Introduction/ Plain Language
Introduction
CIGNA
HealthCare of Arizona, Inc.
11001 N. Black Canyon Hwy., Suite 400
Phoenix, AZ 85029
This brochure describes the benefits of CIGNA HealthCare of Arizona, Inc.
under our contract (CS 1655) with the
Office of Personnel Management (OPM),
as authorized by the Federal Employees Health Benefits law. This brochure
is
the official statement of benefits. No oral statement can modify or otherwise
affect the benefits, limitations, and
exclusions of this brochure.
If you are enrolled in this Plan, you are entitled to the benefits described
in this brochure. If you are enrolled for Self
and Family coverage, each
eligible family member is also entitled to these benefits. You do not have a
right to benefits
that were available before January 1, 2001, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and premiums with each plan annually. Benefit changes
are effective January 1, 2001, and
are summarized on page 47. Rates are
shown at the end of this brochure.
Plain Language
The President and Vice President are making the
Government's communication more responsive, accessible, and
understandable
to the public by requiring agencies to use plain language. In response, a team
of health plan
representatives and OPM staff worked cooperatively to make
this brochure clearer. Except for necessary technical
terms, we use common
words. "You" means the enrollee or family member; "we" means
CIGNA HealthCare of
Arizona, Inc.
The plain language team reorganized the brochure and the way we describe our
benefits. When you compare this Plan
with other FEHB plans, you will find
that the brochures have the same format and similar information to make
comparisons easier.
If you have comments or suggestions about how to improve this brochure, let
us know. Visit OPM's "Rate Us"
feedback area at www. opm. gov/
insure or e-mail us at fehbwebcomments@ opm. gov or write to OPM at Insurance
Planning and Evaluation Division, P. O. Box 436, Washington, DC 20044-0436.
4
4 Page 5 6
5 2001 CIGNA HealthCare of Arizona, Inc.
Section 1. Facts about this HMO plan
Section 1
This Plan is a health maintenance organization (HMO). We require you to
see specific physicians, hospitals, and other
providers that contract with
us. These Plan providers coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in
addition to treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing
any course of treatment.
When you receive services from Plan providers, you will not have to submit
claim forms or pay bills. You only pay the
copayments, coinsurance, and
deductibles described in this brochure. When you receive emergency services from
non-Plan
providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because
a particular provider is available.
You cannot change plans because a
provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract
with us.
How we pay providers
We contract with individual physicians,
medical groups, and hospitals to provide the benefits in this brochure. These
Plan providers accept a negotiated payment from us, and you will only be
responsible for your copayment or
coinsurance. We compensate our
participating providers in ways that are intended to emphasize preventive care,
promote quality of care, and assure the most appropriate use of medical
services. You can discuss with your provider
how he is compensated by us.
The methods we use to compensate participating providers are:
Discounted fee for service Ð Payment for service is based on an agreed
upon discounted amount for the services
provided.
Capitation Ð Physicians, provider groups, and physician/ hospital
organizations are paid a fixed amount at regular
intervals for each Member
assigned to the physician, provider group or physician/ hospital organization,
whether or not
services are provided. This payment covers the physician and/
or, where applicable, hospital or other services covered
under the benefit
plan. Medical groups and physician/ hospital organizations may in turn
compensate providers using a
variety of methods.
Capitation offers health care providers a predictable income, encourages
Physicians to keep people well through
preventive care, eliminates the
financial incentive to provide services that will not benefit the patient, and
reduces
paperwork.
Providers paid on a "capitated" basis may participate with us in a
risk sharing arrangement. They agree upon a target
amount for the cost of
certain health care services, and they share all or some of the amount by which
actual costs are
over target. Provider services are monitored for
appropriate utilization, accessibility, quality and Member satisfaction.
We may also work with third parties who administer payments to Participating
Providers. Under these arrangements,
we pay the third party a fixed monthly
amount for these services. Providers are compensated by the third party for
services provided to Healthplan participants from the fixed amount. The
compensation varies based on overall
utilization.
Salary Ð Physicians and other providers who are employed to work in our
medical facilities are paid a salary. The
compensation is based on a dollar
amount, decided in advance each year, that is guaranteed regardless of the
services
provided. Physicians are eligible for any annual bonus based on
quality of care, quality of service and appropriate use
of Medical Services.
Bonuses and Incentives Ð Eligible Physicians may receive additional
payments based on their performance. To
determine who qualifies, we evaluate
Physician performance using criteria that may include quality of care, quality
of
service, accountability and appropriate use of Medical Services. 5
5 Page 6 7
6 2001 CIGNA HealthCare of Arizona, Inc. Section 1
Section 1. Facts about this HMO Plan (continued)
Per Diem Ð A specific amount is paid to a hospital per day for
all health care received. The payment may vary by type
of service and length
of stay.
Case Rate Ð A specific amount is paid for all the care received in the
hospital for each standard service category as
specified in our contract
with the provider (e. g., for a normal maternity delivery).
Who provides my health care?
We contract with a group of doctors
and hospitals to provide your health care. You will select a primary care
physician
who supervises your total health care needs. You may see a Plan
gynecologist for annual routine examination without a
referral.
Patients' Bill of Rights
OPM requires that all FEHB Plans comply
with the Patients' Bill of Rights, recommended by the President's Advisory
Commission on Consumer Protection and Quality in the Health Care Industry.
You may get information about us, our
networks, providers, and facilities.
OPM's FEHB website (www. opm. gov/ insure) lists the specific types of
information
that we must make available to you. Some of the required
information is listed below.
° CIGNA HealthCare of Arizona is in compliance with all State and Federal
licensing and certification requirements
and has received its certification
by the National Committee on Quality Assurance (NCQA) in April, 1998 and will
go through recredentialing in 2001.
° CIGNA HealthCare of Arizona is a Health Care Services Organization
licensed in the State of Arizona since 1977.
If you want more information
about us, call 1-800-832-3211, or write to CIGNA HealthCare of Arizona, Inc.,
11001 N. Black Canyon Hwy., Suite 400, Phoenix, AZ 85029. You may also visit
our website at
www. cigna. com/ healthcare.
Service Area
To enroll with us, you must live in our service area.
This is where our providers practice. Our service area is:
Maricopa County
and Apache Junction.
Ordinarily, you must get your care from providers who contract with us. If
you receive care outside our service area,
we will pay only for emergency
care. We will not pay for any other health care services.
If you or a covered family member move outside of our service area, you can
enroll in another plan. If your dependents
live out of the area (for
example, if your child goes to college in another state), you should consider
enrolling in a
fee-for-service plan or an HMO that has agreements with
affiliates in other areas. If you or a family member move,
you do not have
to wait until Open Season to change plans. Contact your employing or retirement
office. 6
6 Page 7
8
7 2001 CIGNA HealthCare of Arizona, Inc.
Section 2. How we change for 2001
Section 2
Program-wide changes
° The plain language team
reorganized the brochure and the way we describe our benefits. We hope this will
make it
easier for you to compare plans.
° This year, the Federal Employees Health Benefits Program is
implementing network mental health and substance
abuse parity. This means
that your coverage for mental health, substance abuse, medical, surgical, and
hospital
services from providers in our plan network will be the same with
regard to deductibles, coinsurance, copays, and
day and visit limitations
when you follow a treatment plan that we approve. Previously, we placed higher
patient
cost sharing and shorter day or visit limitations on mental health
and substance abuse services than we did on
services to treat physical
illness, injury, or disease.
° Many healthcare organizations have turned their attention this past
year to improving healthcare quality and patient
safety. OPM asked all FEHB
plans to join them in this effort. You can find specific information on our
patient safety
activities by calling our Member Services Department at
1-800-832-3211, or checking our website,
www. cigna. com/ healthcare.
You can find out more about patient safety on the OPM website, www. opm. gov/
insure.
To improve your healthcare, take these five steps:
° ° Speak up if you have questions or concerns.
° ° Keep
a list of all the medicines you take.
° ° Make sure you get the
results of any test or procedure.
° ° Talk with your doctor and
health care team about your options if you need hospital care.
° °
Make sure you understand what will happen if you need surgery.
° We
clarified the language to show that anyone who needs a mastectomy may choose to
have the procedure
performed on an inpatient basis and remain in the
hospital up to 48 hours after the procedure. Previously, the
language
referenced only women.
Changes to this Plan
° Your share of the non-Postal premium
will increase by 19.4% for Self Only or 17.4% for Self and Family.
° Prescription drugs per unit or refill are covered. You pay a copay of
$5, for generic drugs and a $15 copay for name
brand drugs. Previously, the
copays were $5 for generic drugs and $10 for name brand drugs.
° Mail Order name brand prescription drugs are covered. You pay a $40
copay for up to a 90-day supply. Previously,
the name brand copay was $20
for up to a 90-day supply. Mail order generic drugs copay will remain at $10 for
up
to a 90-day supply.
° Heart/ Lung has been added to the list of covered organ/ tissue
transplants.
° We clarified the summary page to show that the vision
benefit copay is $10 instead of $5. 7
7 Page 8 9
8 2001 CIGNA
HealthCare of Arizona, Inc. Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when
you enroll. You should carry your ID card with you at all times. You must show
it whenever you
receive services from a Plan provider, or fill a
prescription at a Plan
pharmacy. Until you receive your ID card, use your
copy of the Health
Benefits Election Form, SF-2809, your health benefits
enrollment
confirmation (for annuitants), or your Employee Express
confirmation
letter.
If you do not receive your ID card within 30 days after the effective date
of your enrollment, or if you need replacement cards, call us at
1-800-832-3211.
Where you get covered care You get care from "Plan
providers" and "Plan facilities." You will only pay copayments,
deductibles, and/ or coinsurance, and you will not have to file
claims
unless you receive emergency services from a provider who does not
have a
contract with us.
° Plan providers Plan providers are physicians and other health
care professionals in our
service area that we contract with to provide
covered services to our
members. We credential Plan providers according to
national standards.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website.
° Plan facilities Plan facilities are hospitals and other
facilities in our service area that we
contract with to provide covered
services to our members. We list these in
the provider directory, which we
update periodically. The list is also on
our website.
It depends on the type of care you need. First, you and each family member
must choose a primary care physician. This decision is important since your
primary care physician provides or arranges for most of your health care.
When you enroll, you choose a Primary Care Physician (PCP). Each family
member also chooses a PCP. Your PCP is your personal doctor and serves
as your health care manager. If you do not select a PCP, we will assign one
for you. If your PCP leaves our network, you will be able to choose a new
PCP. You may voluntarily change your PCP for other reasons but not more
than once in any calendar month. We reserve the right to determine the
number of times during a year that you will be allowed to change your PCP.
If you select a new PCP before the fifteenth day of the month, the
designation will be effective on the first day of the month following your
selection. If you select a new PCP on or after the fifteenth day of the
month, the designation will be effective on the first day of the month
following the next full month. For example, if you notify us on June 10, the
change will be effect on July 1. If you notify us on June 15, the change
will
be effective on August 1.
Some Primary Care Physicians belong to provider organizations which
usually refer to a network of Specialty Care Physicians and Hospitals that
are in the provider organization. Your choice of Primary Care Physician may
affect the Hospital( s) and Specialty Care Physicians to which you may be
referred. Therefore, you may not have access to every specialist or
Participating Provider in your Service Area. Before you select a PCP, you
should check to see if that PCP is associated with the specialist or
facility
you prefer to use.
What you must do to get covered care 8
8
Page 9 10
9 2001
CIGNA HealthCare of Arizona, Inc.
Section 3. How you get care
(continued)
Section 3
° Primary care Your primary care physician can be a general
practitioner, family
practitioner, internist or pediatrician. Your primary
care physician will
provide most of your health care, or give you a referral
to see a specialist.
If you want to change primary care physicians or if your primary care
physician leaves the Plan, call us. We will help you select a new one.
° Specialty care Your primary care physician will refer you to a
specialist for needed care.
However, you may see an OB/ GYN for well-woman
care or go to a hospital
for emergency care without a referral.
Here are other things you should know about specialty care:
° If you
need to see a specialist frequently because of a chronic, complex,
or
serious medical condition, your primary care physician will work
with the
Plan to develop a treatment plan that allows you to see your
specialist for
a certain number of visits without additional referrals.
Your primary care
physician will use our criteria when creating your
treatment plan (the
physician may have to get an authorization or
approval beforehand).
° If you are seeing a specialist when you enroll in our Plan, talk to
your
primary care physician. Your primary care physician will decide what
treatment you need. If he or she decides to refer you to a specialist, ask
if you can see your current specialist. If your current specialist does not
participate with us, you must receive treatment from a specialist who
does. Generally, we will not pay for you to see a specialist who does
not participate with our Plan.
° If you are seeing a specialist and your specialist leaves the Plan,
call
your primary care physician, who will arrange for you to see another
specialist. You may receive services from your current specialist until
we can make arrangements for you to see someone else.
° If you have a chronic or disabling condition and lose access to your
specialist because we:
° ° terminate our contract with your specialist for other than
cause; or
° ° drop out of the Federal Employees Health
Benefits (FEHB)
Program and you enroll in another FEHB Plan; or
° ° reduce our service area and you enroll in another FEHB
Plan,
you may be able to continue seeing your specialist for up to 90 days
after you receive notice of the change. Contact us or, if we drop out of
the Program, contact your new plan.
If you are in the second or third trimester of pregnancy and you lose access
to your specialist based on the above circumstances, you can continue to see
your specialist until the end of your postpartum care, even if it is beyond
the
90 days. 9
9 Page
10 11
10 2001 CIGNA HealthCare of
Arizona, Inc. Section 3
° Hospital care Your Plan primary
care physician or specialist will make necessary hospital
arrangements and
supervise your care. This includes admission to a skilled
nursing or other
type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our
Member Services Department immediately at 1-800-832-3211. If you are
new
to the FEHB Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for
the hospital stay until:
° You are discharged, not merely moved to an alternative care center; or
° The day your benefits from your former plan run out; or
° The
92nd day after you become a member of this Plan, whichever
happens first.
These provisions apply only to the benefits of the hospitalized person.
Circumstances beyond Under certain extraordinary circumstances, such
as natural disasters, we our control may have to delay your services or
we may be unable to provide them.
In that case, we will make all reasonable
efforts to provide you with the
necessary care.
Services requiring our Your primary care physician has authority to
refer you for most services. prior approval For certain services,
however, your physician must obtain approval from us.
Before giving
approval, we consider if the service is covered, medically
necessary, and
follows generally accepted medical practice.
A referral or Prior Authorization must be obtained prior to receiving
services performed by any health care provider EXCEPT for:
° Services provided by your Primary Care Physician;
° OB/ GYN
Services; and
° Emergency Services or Urgently Needed Care.
A
Referral must be obtained directly from your Primary Care Physician.
Your
Primary Care Physician must provide a referral if you receive services
and
benefits such as Specialty Care Physician services. If you receive
services
which require a referral without a referral from your Primary Care
Physician, you will be obligated to pay for the unauthorized Services.
We will not pay for such unauthorized Services.
Certain benefits and services require Prior Authorization from us. Prior
Authorization must always be obtained through your Plan Provider. If Prior
Authorization is required from us, your Primary Care Physician or Specialty
Care Physician will make arrangements with our Medical Director. Prior
Authorization is required for the following types of benefits and services
such as: Inpatient and Outpatient Hospital Services, Rehabilitative Therapy,
Skilled Nursing Facility Services, Home Health Services, Second Surgical
Opinions, Services provided by a Non-Plan Provider, Durable Medical
Equipment and Prosthetic Devices.
If your coverage is terminated prior to the date of service, the service will
not be covered, regardless of any Prior Authorization given by us or your
Primary or Specialty Care Physician. 10
10
Page 11 12
11
2001 CIGNA HealthCare of Arizona, Inc.
Section 4. Your costs for
covered services
You must share the cost of some services. You are
responsible for:
° Copayments A copayment is a fixed amount of
money you pay to the provider when you
receive services.
Example: When you see your primary care physician you pay a copayment
of
$10 per office visit.
° Deductible A deductible is a fixed expense you must incur for
certain covered services
and supplies before we start paying benefits for
them. We do not have a
deductible.
Note: If you change plans during open season, you do not have to start a
new deductible under your old plan between January 1 and the effective date
of your new plan. If you change plans at another time during the year, you
must begin a new deductible under your new plan.
After your copayments total $1,500 per person or $3,000 per family
enrollment in any calendar year, you do not have to pay any more for
covered services. However, copayments for the following services do not
count toward your out-of-pocket maximum, and you must continue to pay
copayments for these services:
° prescription drugs
° vision
° mental health/ substance
abuse
° durable medical equipment
° external prosthetic
appliances
Be sure to keep accurate records of your copayments since you are
responsible for informing us when you reach the maximum.
Section 4
Your out-of-pocket maximum for copayments 11
11 Page 12 13
12 2001 CIGNA HealthCare of Arizona, Inc. Section 5
Section 5. Benefits Ð OVERVIEW (See page 7 for how our
benefits changed this year and page 47 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Also read
the General Exclusions in Section 6; they
apply to the benefits in the
following subsections. Please read the important things you should keep in mind
at the
beginning of each subsection. To obtain claims forms, claims filing
advice, or more information about our ben-efits,
contact us at
1-800-832-3211 or at our website at www. cigna. com/ healthcare.
(a) Medical services and supplies provided by physicians and other health
care professionals ........................... 13-18
° Diagnostic and
treatment services ° Hearing services (testing, treatment, and supplies)
° Lab, X-ray, and other diagnostic tests ° Vision services (testing,
treatment, and supplies)
° Preventive care, adult ° Foot care
° Preventive care, child ° Orthopedic and prosthetic devices
° Maternity care ° Durable medical equipment (DME)
° Family
planning ° Home health services
° Infertility services °
Alternative treatments
° Allergy care ° Educational classes and
programs
° Treatment therapies
° Rehabilitative therapies
(b) Surgical and anesthesia services provided by physicians and other health
care professionals ....................... 19-21
° Surgical procedures
° Oral and maxillofacial surgery
° Reconstructive surgery °
Organ/ tissue transplants
° Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services
...................................................... 22-23
° Inpatient
hospital ° Extended care benefits/
° Outpatient hospital or skilled
nursing care facility benefits
ambulatory surgical center ° Hospice care
° Ambulance
(d) Emergency services/ accidents
..........................................................................................................................
24-25
° Medical Emergency ° Ambulance
(e) Mental health and substance abuse benefits
.....................................................................................................
26-27
(f) Prescription drug benefits
.................................................................................................................................
28-29
(g) Special features
................................................................................................................................................
30
(h) Dental benefits
.................................................................................................................................................
31
(i) Non-FEHB benefits available to Plan members
.............................................................................................
32
Summary of benefits
................................................................................................................................................
47 12
12 Page 13
14
13 2001 CIGNA HealthCare of Arizona, Inc.
Section 5( a)
Medical services and supplies provided by physicians
and other health care professionals
I
M
P
O
R
T
A
N
T
I
M
P
O
R
T
A
N
T
Here are some important things to keep in mind about these benefits:
° Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are
medically necessary.
° Plan physicians must provide or arrange your
care.
° We have no calendar year deductible.
° Be sure to read
Section 4, Your costs for covered services for valuable information about
how cost sharing works. Also read Section 9 about coordinating benefits with
other coverage, including with Medicare.
You pay Benefit Description
Diagnostic and treatment services
Professional services of physicians $10 per office visit
° In
physician's office
° At home
° In an urgent care center
° During a hospital stay
° In a skilled nursing facility
° Initial examination of a newborn child covered under a family
enrollment
° Office medical consultations
° Second surgical opinion
° After hours $20 per office visit
Lab, X-ray and other diagnostic
tests
Preventive care, adult
Section 5 (a).
Tests such as: Nothing
° Blood tests
° Urinalysis
° Pap tests
° Pathology
° X-rays
° Mammograms
° CAT Scans/ MRI
° Ultrasound
°
Electrocardiogram and EEG
Note: You pay nothing for Lab, X-rays and other diagnostic tests, however
a provider or facility copayment may apply. Refer to the provider/ facility
charges identified in this Section 5.
Routine screenings, such as: Nothing
° Blood lead level Ð one
annually ° Total Blood Cholesterol Ñ once every three years, ages 19
through 64
° Colorectal Cancer Screening, including
° ° Fecal occult
blood test
° ° Sigmoidoscopy, screening Ñ every five years
starting at age 50 Nothing 13
13 Page 14 15
14 2001 CIGNA
HealthCare of Arizona, Inc.
Preventive care, children
Preventive
care, adult (CONTINUED)
Prostate Specific Antigen (PSA
test) Ð one annually for men age 40 and older Nothing
Routine pap test Nothing
Note: The office visit is covered if pap test is
received on the same day; see Diagnostic and Treatment Services, on page
13.
Note: You pay nothing for routine screenings, however a provider or facility
copayment may apply. Refer to the provider/ facility charges
identified in
this Section 5.
Routine mammogram Ð covered for women age 35 and older,
as follows: Nothing
° From age 35 through 39, one during this five year
period
° From age 40 through 64, one every calendar year
° At
age 65 and older, one every two consecutive calendar years
Not Covered: Physical exams required for obtaining or continuing All
charges
employment or insurance, attending schools or camp, or travel.
Routine Immunizations, limited to: Nothing
° Tetanus-diphtheria (Td)
booster Ð once every 10 years, ages 19 and over (except as provided for
under Childhood Immunizations)
° Influenza/ Pneumococcal vaccines, annually, age 65 and over
Maternity care
Complete maternity (obstetrical) care, such as:
° Prenatal care ° Delivery
° Postnatal care
Note: Here are some things to keep in mind Ð
° You do not need to obtain prior approval for your normal delivery; see
page
10 for other circumstances, such as extended stays for you or your baby.
° You may remain in the hospital up to 48 hours after a regular delivery
and 96 hours after a cesarean delivery. We will extend your inpatient stay if
medically necessary.
° We cover routine nursery care of the newborn
child during the covered portion of the mother's maternity stay. We will cover
other care of an infant
who requires non-routine treatment only if we cover the infant under a Self
and Family enrollment.
° We pay hospitalization and surgeon services (delivery) the same as for
illness and injury. See Hospital benefits (Section 5c) and Surgery
benefits
(Section 5b).
$10 for the first office visit to confirm pregnancy;
no copay for all
pre-/ post-delivery visits thereafter.
Section 5( a)
You pay
Not Covered: Routine sonograms to determine fetal age,
size or sex. All charges
° Childhood immunizations and injections
recommended by the Nothing American Academy of Pediatrics
Note: You pay
nothing for childhood immunizations, however a provider or facility copayment
may apply. Refer to the provider/ facility
charges identified in this
Section 5.
° Examinations, such as: $10 per office visit
° °
Eye exams through age 17 to determine the need for vision correction
°
° Ear exams through age 17 to determine the need for hearing correction
° ° Examinations done on the day of immunizations (through age 22)
° Well-child care charges for routine examinations, immunizations and
care (through age 22) 14
14 Page 15 16
15 2001 CIGNA
HealthCare of Arizona, Inc. Section 5( a)
Infertility services
Diagnosis of infertility $20 per office visit
Treatment of
infertility, such as: $20 per office visit
° Artificial insemination:
° ° intravaginal insemination (IVI)
° Fertility drugs
Note: We cover injectable fertility drugs under
medical benefits and oral fertility drugs under the prescription drug benefit.
Family planning
° Voluntary sterilization Nothing
Note:
You pay nothing for voluntary sterilization, however a provider or facility
copayment may apply. Refer to the provider/ facility charges
identified in this Section 5.
° Surgically implanted contraceptives
$10 per office visit
° Injectable contraceptive drugs
°
Intrauterine devices
Not Covered: Reversal of voluntary surgical sterilization, genetic
counseling. All charges
Not Covered: All charges
° Assisted reproductive technology
(ART) procedures, such as:
° ° in vitro fertilization
° ° embryo transfer and GIFT
° Services and
supplies related to excluded ART procedures
° Cost of donor sperm
Allergy care
Testing and treatment $10 per office visit
Allergy injection
Allergy serum Nothing
Treatment therapies
° Chemotherapy
and radiation therapy Nothing
Note: High dose chemotherapy in association
with autologous bone marrow transplants are limited to those transplants listed
under Organ/ Tissue Transplants
on page 21.
° Respiratory and inhalation therapy
° Dialysis
Ð Hemodialysis and peritoneal dialysis
° Intravenous (IV)/ Infusion
therapy Ð Home IV and antibiotic therapy
° Growth hormone therapy
(GHT)
Note: We will only cover GHT when your PCP has received our prior
authorization. Prior approval must be received before you begin treatment,
otherwise, we will only cover GHT services from the date your PCP receives
prior authorization. If prior authorization is not received or if we determine
GHT is not medically necessary, we will not cover the GHT or related
services and supplies. GHT is covered under the prescription drug benefit. See
Services
requiring our prior approval in Section 3.
You pay 15
15 Page
16 17
16 2001 CIGNA HealthCare of
Arizona, Inc.
Not Covered: All charges
° long-term rehabilitative
therapy
° exercise programs
° cardiac and pulmonary
rehabilitation programs
° One annual eye refraction, which may include a lens prescription, per
year $10 per office visit
° One pair of eyeglasses or contact lenses for
treatment of keratoconus or $10 per office visit post-cataract surgery
° One pair of single vision glass or plastic lenses per year
°
Eye exam to determine the need for vision correction for children $10 per office
visit through age 17 (See Preventive care)
Hearing services (testing, treatment, and supplies)
° Hearing
testing for children through age 17 (see Preventive care, children) $10
per office visit
Rehabilitative therapies
Not Covered: All charges
° all other hearing testing
° hearing aids, testing and examinations for them
Foot care
Routine foot care when you are under active treatment
for medical conditions such as diabetes; fungal infection of the nail bed;
circulatory impairment;
immunocompromised patients.
See Orthopedic and prosthetic devices
for information on podiatric shoe inserts.
Section 5( a)
Not Covered: All charges
° Eyeglasses Ð examinations
for them in excess of one per year
° Contact lenses and exams for
them
° Eye exercises and orthoptics
° Radial
keratotomy and other refractive surgery
Vision services (testing, treatment, and supplies)
Not Covered: All charges
° Cutting, trimming or removal of
corns, calluses, or the free edge of toenails, and similar routine treatment of
conditions of the foot,
except as stated above.
° Treatment of weak, strained or
flat feet or bunions or spurs; and of any instability; imbalance or subluxation
of the foot (unless the treatment is
by open cutting surgery).
Physical therapy, occupational therapy and speech therapy Ð $10 per
office visit
° 60 consecutive days total per condition for the services
of each of the following:
° ° qualified physical therapists;
° ° speech therapists;
° ° occupational therapists; and
° ° chiropractors.
Note: We only cover therapy to restore bodily function or speech when there
has been a total or partial loss of bodily function or functional speech
due to illness or injury.
You pay
$10 per office visit 16
16 Page 17 18
17 2001 CIGNA
HealthCare of Arizona, Inc. Section 5( a)
Orthopedic and prosthetic
devices
° Artificial limbs and eyes; hands or hooks. First $200 per
calendar year and all charges after
the annual maximum Plan payment of $1,000 for all
devices
Durable medical equipment (DME)
Rental or purchase, at our option,
including repair and adjustment, of durable medical equipment prescribed by your
Plan physician and received
from a vendor approved by the Plan, such as oxygen tents and dialysis
equipment. Under this benefit, we also cover:
° hospital beds;
° wheelchairs (limited to the lowest cost
alternative to satisfy medical necessity);
° crutches;
°
walkers;
° blood glucose monitors and blood glucose monitors for the
legally blind;
° insulin pumps and infusion devices;
°
respirators; and
° oxygen tents
Note: Your PCP will prescribe and arrange for a participating health care
provider to rent or sell you the durable medical equipment. We will not cover
equipment received from a non-participating health care provider unless your
PCP has received our prior authorization.
Not covered:
° Hygienic or self-help items or equipment, or items
or equipment that are primarily for comfort or convenience, such as bathtub
chairs, safety grab bars,
stair gliders or elevators, over-the-bed tables, saunas or exercise
equipment;
° Environmental control equipment, such as air purifiers,
humidifiers, and
electrostatic machines;
° Institutional equipment such as air fluidized beds and diathermy
machines;
° Consumable medical supplies including, but not limited to,
bandages and other disposable supplies, skin preparations, test strips, ostomy
supplies,
surgical leggings, elastic stockings and wigs.
° Externally worn breast prostheses and surgical bras, including
necessary Nothing replacements.
° Internal prosthetic devices, such as
artificial joints, pacemakers, cochlear implants, and surgically implanted
breast implant following
mastectomy.
Not Covered: All charges
° orthopedic and corrective shoes
° arch supports
° foot orthotics
° heel pads and heel cups
°
lumbosacral supports
° corsets, trusses, elastic stockings, support
hose, and other supportive devices
° prosthetic replacements due to wear
and tear, loss, theft, or destruction
° corrective orthopedic appliances
for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction
syndrome
° biomechanical devices
° penile prosthetics
Nothing
All charges
You pay 17
17 Page
18 19
18 2001 CIGNA HealthCare of
Arizona, Inc.
Home health services
° Home health care
ordered by a Plan physician and provided by a registered Nothing nurse (R. N.),
licensed practical nurse (L. P. N.), licensed vocational nurse
(L. V. N.), or home health aide.
° Services include oxygen therapy,
intravenous therapy and medications.
Not Covered: All charges
° nursing care requested by, or for the
convenience of, the patient or the
patient's family;
° nursing care primarily for hygiene, feeding, exercising, moving the
patient, homemaking, companionship or giving oral medication;
° services primarily for rest, domiciliary or convalescent care.
Educational classes and programs
Section 5( a)
Alternative treatments
Coverage includes programs such as: $10 per
class
° Wellness classes for children such as:
° ° Acne
Ð Skin Deep
° ° Adolescent Weight Loss Ð Why Weight?
° ° Tobacco Management Ð Arizona Smokers Helpline
° Wellness classes for adults such as:
° ° Back Care Ð
Oh! My Aching Back
° ° Weight Management
° ° Tobacco
Management
° ° Women's Health
° Diabetes Education Classes $25 per treatment program
No benefit All charges
You pay 18
18 Page 19 20
19 2001 CIGNA HealthCare of Arizona, Inc. Section
5( b)
I
M
P
O
R
T
A
N
T
I
M
P
O
R
T
A
N
T
You pay Benefit Description
Surgical procedures
°
Treatment of fractures, including casting Nothing
° Normal pre-and
post-operative care by the surgeon
° Correction of amblyopia and
strabismus
° Endoscopy procedure
° Biopsy procedure
°
Removal of tumors and cysts
° Correction of congenital anomalies (see
reconstructive surgery)
° Surgical treatment of morbid obesity Ñ
a condition in which an individual weighs 200% of his or her normal weight
according to the
1983 Metropolitan Life Insurance Company height-weight chart with a history
of morbid obesity for at least 5 years and has complied with more
conservative methods of weight loss
° Insertion of internal
prosthetic devices. See 5( a) Ð Orthopedic braces and prosthetic devices
for device coverage information.
° Voluntary sterilization Nothing
° Norplant (a surgically
implanted contraceptive) and intrauterine devices (IUDs). Note: Devices are
covered under 5( a).
° Treatment of burns
Note: Generally, we pay for internal prostheses
(devices) according to where the procedure is done. For example, we pay Hospital
benefits for a
pacemaker and Surgery benefits for insertion of the pacemaker.
Surgical procedures continued on next page.
Here are some important things to keep in mind about these benefits:
° Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically
necessary.
° Plan physicians must provide or arrange your care.
° We have no calendar year deductible.
° Be sure to read Section
4, Your costs for covered services for valuable information about how
cost sharing works. Also read Section 9 about coordinating benefits with
other coverage, including with Medicare
° The amounts listed below
are for the changes billed by a physician or other health care professional for
your surgical care. Look in Section 5( c) for charges associated
with this facility (i. e., hospital, surgical center, etc.)
°
YOU MUST GET PRIOR AUTHORIZATION OF SOME SURGICAL PROCEDURES. Please refer to
the prior authorization information shown in Section
3 to be sure which services require prior authorization and identify which
surgeries require prior authorization.
Surgical and anesthesia services provided by physicians and other health
care professionals Section 5 (b). 19
19 Page 20 21
20 2001 CIGNA
HealthCare of Arizona, Inc.
Not Covered: All charges
° Cosmetic
surgery Ð any surgical procedure (or any portion of a
procedure)
performed primarily to improve physical appearance through change in bodily
form, except repair of accidental injury.
° Surgeries related to sex transformation.
Oral and
maxillofacial surgery
Oral surgical procedures, such as: Nothing
° Reduction of fractures of the jaws or facial bones;
° Surgical
correction of cleft lip, cleft palate or severe functional malocclusion;
° Removal of stones from salivary ducts;
° Excision of
leukoplakia or malignancies;
° Excision of cysts and incision of
abscesses when done as independent procedures; and
° Other surgical procedures that do not involve the teeth or their
supporting structures.
Not Covered: All charges
° Oral implants and transplants.
° Procedures that involve the teeth or their supporting structures
(such as the periodontal membrane, gingiva, and alveolar bone).
° Other surgical procedures which have not received prior approval
from the Plan Medical Director.
Surgical procedures (CONTINUED)
Not Covered: All
charges
° Reversal of voluntary sterilization.
° Routine
treatment of conditions of the foot; see Foot care.
° Cosmetic therapy
or surgery primarily for the purpose of altering appearance.
Reconstructive surgery
° Surgery to correct a functional
defect Nothing
° Surgery to correct a condition caused by injury or
illness if:
° ° the condition produced a major effect on the
member's appearance and
° ° the condition can reasonably be expected
to be corrected by such surgery.
° Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of
congenital
anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks;
webbed fingers; and webbed toes.
° All stages of breast reconstruction surgery following a mastectomy,
such as: Nothing
° ° surgery to produce a symmetrical appearance on
the other breast;
° ° treatment of any physical complications, such
as lymphedemas;
° ° breast prostheses and surgical bras and
replacements (see Prosthetic devices).
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48 hours
after the procedure.
Section 5( b)
You pay 20
20 Page
21 22
21 2001 CIGNA HealthCare of
Arizona, Inc. Section 5( b)
Organ/ tissue transplants
Professional services provided in Ð Nothing
° Hospital
(inpatient)
° Hospital outpatient department
° Skilled nursing
facility
° Ambulatory surgical center
° Office
Limited to: Nothing
° Cornea
° Heart
° Heart/ Lung
° Kidney
°Liver
° Allogeneic (donor) bone marrow
transplants
° Autologous bone marrow transplants (autologous stem cell
and peripheral stem cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's lymphoma;
advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer;
multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal,
retroperitoneal and ovarian germ
cell tumors.
° National Transplant
Program (NTP) -Please refer to Section 5( g) Special Features to learn
about CIGNA's Lifesource Organ Transplant Network.
Limited Benefits Ð Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI-or NIH-approved
clinical
trial at a Plan-designated center of excellence and if approved by the Plan's
Medical Director in accordance with the Plan's protocols.
Note: We cover related medical and hospital expenses of the donor when we
cover the recipient.
Not Covered: All charges
° Donor screening tests and donor search
expenses, except those
performed for the actual donor
° Implants of artificial organs
° Transplants not listed as
covered
Anesthesia
You pay 21
21 Page
22 23
22 2001 CIGNA HealthCare of
Arizona, Inc. Section 5( c)
I
M
P
O
R
T
A
N
T
I
M
P
O
R
T
A
N
T
You pay Benefit Description
Inpatient hospital
Room and board,
such as Nothing
° ward, semiprivate, or intensive care accommodations;
° general nursing care; and
° meals and special diets.
Note: If you want a private room when it is not medically necessary, you pay
the additional charge above the semiprivate room rate.
Other hospital services and supplies, such as: Nothing
° Operating,
recovery, maternity, and other treatment rooms
° Prescribed drugs and
medicines
° Diagnostic laboratory tests and X-rays
°
Administration of blood, blood products and other biologicals
° Blood or
blood plasma
° Dressings, splints, casts, and sterile tray services
° Medical supplies and equipment, including oxygen
° Anesthetics
and anesthesia services
Not Covered: All charges
° Custodial care
° Non-covered
facilities, such as nursing homes, skilled nursing
facilities, schools
° Personal comfort items, such as telephone, television, barber
services,
guest meals and beds
° Private nursing care
Here are some important things to remember about these benefits:
° Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically
necessary.
° Plan physicians must provide or arrange your care and
you must be hospitalized in a Plan facility.
° We have no calendar year deductible.
° Be sure to read Section
4, Your costs for covered services for valuable informaion about how cost
sharing works. Also read Section 9 about coordinating benefits with
other coverage, including with Medicare.
° The amounts listed below
are for the changes billed by the facility (i. e., hospital or surgical
center) or ambulance service for your surgery or care. Any costs associated
with the professional charge (i. e., physician, etc.) are covered in
Section 5( a) or (b).
° Your Primary Care Physician must obtain our
Prior Authorization for Hospital Stays, except for emergencies.
Services provided by a hospital or other facility, and ambulance services
Section 5 (c). 22
22 Page
23 24
23 2001 CIGNA HealthCare of
Arizona, Inc.
Hospice care
Supportive and palliative care for
a terminally ill member is covered. Nothing Services are provided under the
direction of a Plan doctor who certifies that
the patient is in the terminal stages of illness, with a life expectancy of
approximately six (6) months or less.
Hospice care services include:
° inpatient care
° outpatient
care
° physician services
° psychologist, social worker or
family counselor services for individual or family counseling
Not covered: All charges
° independent nursing;
°
homemaker services, including services and supplies that are primarily
to
aid you or your dependent in daily living;
° services of a person who is
a member of your family who normally
resides in your house;
°
services or supplies not listed in the Hospice Care Program;
° services
for curative or life-prolonging procedures;
° services for respite care;
° nutritional supplements, non-prescription drugs or substances,
medical supplies, vitamins or minerals;
° bereavement counseling.
Section 5( c)
Outpatient hospital or ambulatory surgical center You pay
Extended
care benefits/ skilled nursing care facility benefits
Benefits will be
provided for up to 60 days per calendar year when full-time Nothing skilled
nursing care is necessary and confinement in a skilled nursing facility
is medically appropriate as determined by a Plan doctor and approved by the
Plan.
° Bed and board
° Skilled and general nursing services
° Physicians visits
° Physiotherapy
° X-rays
°
Administration of drugs, medications and fluids
Not Covered: All charges
° Personal comfort items, such as
television and telephone
° Custodial care, rest cures, domiciliary or
convalescent care
° Operating, recovery, and other treatment rooms Nothing
°
Prescribed drugs and medicines
° Diagnostic laboratory tests, X-rays,
and pathology services
° Administration of blood, blood products and
other biologicals
° Blood and blood plasma
° Pre-surgical
testing
° Dressings, casts, and sterile tray services
° Medical
supplies, including oxygen
° Anesthetics and anesthesia services
Note: We cover hospital services and supplies related to dental procedures
when necessitated by a non-dental physical impairment. We do not cover
the dental procedures.
Not Covered: blood and blood derivatives not
replaced by the member. All charges
Ambulance
° Local professional ambulance service when
medically appropriate. Nothing 23
23 Page 24 25
24 2001 CIGNA
HealthCare of Arizona, Inc.
Emergency services/ accidents
Section 5( d)
I M
P O
R T
A N
T
I M
P O
R T
A N
T
Section 5 (d).
Here are some important things to keep in mind about
these benefits:
° Please remember that all benefits are subject to
the definitions, limitations, and exclusions in this brochure.
° We have no calendar year deductible.
° Be sure to read Section
4, Your costs for covered services for valuable information about how
cost sharing works. Also read Section 9 about coordinating benefits with
other coverage, including with Medicare.
What is a medical emergency? A medical emergency is the sudden and
unexpected onset of a condition or an injury that you believe endangers your
life or could result in serious injury or disability, and requires immediate
medical or surgical care. Some problems
are emergencies because, if not
treated promptly, they might become more serious; examples include deep cuts and
broken bones. Others are emergencies because they are potentially
life-threatening, such as heart attacks, strokes,
poisonings, gunshot
wounds, or sudden inability to breathe. There are many other acute conditions
that we may
determine are medical emergencies Ð what they all have in
common is the need for quick action.
What to do in case of emergency: Emergencies inside or outside our service
area: In the event of an emergency, get help immediately. Go to the
nearest emergency room, the nearest hospital or call or ask someone to call
911 or your local emergency service,
police or fire department for help. You
do not need a referral from your PCP for Emergency Services, but you do need
to call your PCP as soon as possible for further assistance and advice on
follow-up care. If you require specialty care
or a hospital admission, your
PCP will coordinate it and handle the necessary authorizations for care or
hospitalization. Participating Providers are on call twenty-four (24) hours
a day, seven (7) days a week, to assist you
when you need Emergency
Services.
If you receive Emergency Services outside the Service Area, you must notify
us as soon as reasonably possible. We
may arrange to have you transferred to
a Participating Provider for continuing or follow-up care if it is determined to
be medically safe to do so.
Emergency Services are defined as the medical, psychiatric, surgical,
hospital and related health care services and
testing, including ambulance
service, which are required for relief of acute pain, for the initial treatment
of acute
infection or to treat a sudden unexpected onset of a bodily injury
or a serious illness which could reasonably be
expected by a prudent
layperson to result in serious medical complications, loss of life or permanent
impairment to
bodily functions in the absence of immediate medical
attention. Examples of emergency situations include
uncontrolled bleeding,
seizures or loss of consciousness, shortness of breath, chest pains or severe
squeezing
sensations in the chest, suspected overdose of medication or
poisoning, sudden paralysis or slurred speech, burns,
cuts, and broken
bones. The symptoms that led you to believe you needed emergency care, as coded
by the provider
and recorded by the hospital on the UB92 claim form or its
successor, or the final diagnosis, whichever reasonably
indicated an
emergency medical condition, will be the basis for the determination of
coverage, provided such
symptoms reasonably indicate an emergency. You are
covered for at least a screening examination to determine
whether an
emergency exists. Care up and through stabilization for emergency situations is
covered without prior
authorization.
Continuing or follow-up treatment, whether in or out of the Service Area, is
not covered unless it is provided or
arranged for by your PCP or upon Prior
Authorization of the Plan Medical Director. 24
24
Page 25 26
25
2001 CIGNA HealthCare of Arizona, Inc. Section 5( d)
You pay
Benefit Description
Emergency outside our service area
Ambulance
° Emergency care at a Plan doctor's office $10 per office visit
°
Emergency care at a Plan urgent care center $20 per visit
° Emergency
care as an outpatient or inpatient at a hospital, $50 per visit. Copayment
including doctors' services waived if admitted to
hospital.
Not Covered: Elective care or non-emergency care. All
charges
° Emergency care at a doctor's office $10 per office visit
°
Emergency care at an urgent care center $20 per visit
° Emergency care
as an outpatient or inpatient at a hospital, $50 per visit. Copayment including
doctors' services waived if admitted to
hospital.
Not Covered: All charges
° Elective care or
non-emergency care.
° Emergency care provided outside the service area
if the need for care
could have been foreseen before leaving the service
area.
Professional ambulance service when medically appropriate. Nothing
See 5(
c) for Non-emergency service.
Emergency within our service area 25
25
Page 26 27
26
2001 CIGNA HealthCare of Arizona, Inc. Section 5( e)
Mental health
and substance abuse benefits
I
M
P
O
R
T
A
N
T
I
M
P
O
R
T
A
N
T
You pay Benefit Description
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider and
Your cost sharing contained in a treatment plan that we approve. The treatment
plan may responsibilities are no
include services, drugs, and supplies described elsewhere in this brochure.
greater than for other illness or conditions.
Note: Plan benefits are payable only when we determine the care is clinically
appropriate to treat your condition and only when you receive
the care as
part of a treatment plan that we approve.
° Professional services,
including individual or group therapy by providers $10 per office visit such as
psychiatrists, psychologists, or clinical social workers.
° Medication management
° Diagnostic tests Nothing
°
Inpatient services provided by a hospital or other facility. Nothing
°
Outpatient Services in approved alternative care settings such as Nothing,
however a partial hospitalization, residential treatment, facility based
intensive provider copayment
outpatient treatment. may apply.
Not Covered: Services we have not
approved. All charges
Note: OPM will base its review of disputes about
treatment plans on the treatment plan's clinical appropriateness. OPM will
generally not order
us to pay or provide one clinically appropriate treatment plan in favor of
another.
Section 5 (e).
Parity
Beginning in 2001, all FEHB plans'
mental health and substance abuse benefits will achieve "parity" with
other benefits. This means that we will provide mental health
and substance abuse benefits differently than in the past.
When you get
our approval for services and follow a treatment plan we approve, cost-sharing
and limitations for Plan mental health and substance abuse benefits will be no
greater than for similar benefits for other illnesses and conditions.
Here are some important things to keep in mind about these benefits:
° All benefits are subject to the definitions, limitations, and
exclusions in this brochure.
° We have no calendar year deductible.
° Be sure to read Section
4, Your costs for covered services for valuable information about how
cost sharing works. Also read Section 9 about coordinating benefits
with other coverage, including with Medicare.
° YOU MUST GET
PREAUTHORIZATION OF THESE SERVICES. See the Instructions after the
benefits description below.
Mental Health continued on next page 26
26
Page 27 28
27
2001 CIGNA HealthCare of Arizona, Inc. Section 5( e)
Preauthorization To be eligible to receive these benefits you
must follow your treatment plan and all the following authorization processes:
Mental Health and Substance Abuse Services are provided by CIGNA
Behavioral Health, Inc. You do not need a referral to receive these
services.
However, to obtain these services, you must call CIGNA
Behavioral Health
directly, their phone number can be found on your ID Card,
to get more
information or speak with someone about a specific problem. A
representa-tive
is available to assist you twenty-four (24) hours a day,
seven (7) days a
week. The representative will provide you with a choice of
providers in
your area and will authorize an appropriate number of visits.
If a mental health or substance abuse professional provider is treating you
under our Plan as of January 1, 2001, you will be eligible for continued
coverage with your provider for up to 90 days under the following condition:
° If your mental health or substance abuse professional provider with
whom you are currently in treatment leaves the plan at our request for
other
than cause.
If this condition applies to you, we will allow you reasonable
time to transfer your care to a Plan mental health or substance abuse
professional
provider. During the transitional period, you may continue to see your
treating provider and will not pay any more out-of-pocket than you did in
the year 2000 for services. This transitional period will begin with our
notice to you of the change in coverage and will end 90 days after you
receive our notice. If we write to you before October 1, 2000, the 90-day
period ends before January 1 and this transitional benefit does not apply.
Limitation We may limit your benefits if you do not follow your
treatment plan.
Special transitional benefit 27
27
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28
2001 CIGNA HealthCare of Arizona, Inc. Section 5( f)
Prescription
drug benefits
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Section 5 (f).
Here are some important things to keep in mind about
these benefits:
° We cover prescribed drugs and medications, as
described in the chart beginning on the next page.
° All benefits are subject to the definitions, limitations, and
exclusions in this brochure and are payable only when we determine they are
medically necessary.
° We have no calendar year deductible.
° Be
sure to read Section 4, Your costs for covered services for valuable
information about how cost sharing works. Also read Section 9 about coordinating
benefits with
other coverage, including with Medicare.
There are important features you should be aware of. These include:
° Who can write your prescription. A plan physician or
licensed dentist must write the prescription .
° Where you can obtain them. You may fill the prescription at a
plan retail pharmacy, or by plan mail-order pharmacy. You must fill the
prescription at a plan retail pharmacy. You may fill your maintenance
medications
by mail through a plan mail-order pharmacy.
° We use a formulary.
A formulary is a listing of approved drug products. The drugs and
medications included have been approved in accordance with parameters
established by Healthplan. This list is subject to periodic
review and is amended as required. Only those medications included on the
formulary are covered.
These are the dispensing limitations.
° Your copayment for generic retail prescription drugs is $5. Your
copayment for name brand retail prescription drugs is $15. Each prescription
order or refill is limited to a consecutive thirty (30) day supply at a retail
participating pharmacy, unless limited by the drug manufacturer's packaging.
° Maintenance medications prescribed by Plan doctors may also be
obtained through our mail order program. Your copayment for generic mail order
prescription drugs is $10. Your copayment for name brand mail order drugs is
$40. Each prescription order or refill is limited to a consecutive ninety
(90) day supply at a mail order participating pharmacy, unless limited by the
manufacturer's packaging.
Each prescription order or refill is further limited to:
°
Those drugs and medicines that appear on the formulary.
°
"Generic" drugs unless a generic alternative does not exist or
substitution is not permitted by state law.
Coverage for prescription drugs
are subject to a Copayment. In no event will the Copayment exceed the cost of
the drug.
In the event you insist on:
(i) a more expensive name brand drug where a
generic drug would otherwise have been dispensed, you are financially
responsible for the amount by which the cost of the name brand drug exceeds the
generic drug,
plus the name brand copayment; or
(ii) a non-formulary drug, you will be
financially responsible for the full cost of the non-Formulary drug.
° When you have to file a claim. Please refer to Section 7
Filing a claim for covered services.
Prescription drug benefits begin on the next page. 28
28 Page 29 30
29 2001 CIGNA HealthCare of Arizona, Inc. Section
5( f)
You pay Benefit Description
Covered medications and
supplies
All charges
We cover the following medications and supplies
prescribed by a Plan physician and obtained from a Plan pharmacy or through our
mail order
program:
° Drugs and medicines that by Federal law of the
United States require a physician's prescription for their purchase, except as
excluded below.
° Insulin
° Disposable needles and syringes for the
administration of covered medications.
° Drugs for sexual dysfunction (contact Plan for dose limits).
°
Oral and contraceptive drugs and contraceptive devices; contraceptive (such as
diaphragms).
° Intravenous fluids and medication for home use, implantable drugs, and
some injectable drugs are covered under Medical and Surgical Benefits.
°
Implanted time release medications, such as Norplant; you pay a one-time copay
of $10 for the office visit. There is no charge when the device is
implanted
during a covered hospitalization.
° Glucose test strips and lancets.
° Diabetic supplies such as test strips.
° Oral agents for
controlling blood sugar.
Here are some things to keep in mind about our prescription drug program:
° A generic equivalent will be dispensed if it is available, unless your
physician specifically requires a name brand. If you receive a name
brand drug when a Federally-approved generic drug is available, and your
physician has not specified Dispense as Written for the name brand drug,
you
have to pay the difference in cost between the name brand drug and the generic.
Not Covered:
° Drugs and supplies for cosmetic purposes
°
Vitamins (except for prenatal vitamins), and fluoride products, nutrients and
food supplements even if a physician prescribes or administers them
° Non-prescription medicines
° Drugs obtained from a non-Plan
pharmacy except for out-of-area emer-gencies
° Medical supplies such as dressings and antiseptics
° Drugs
to enhance athletic performance
° Smoking cessation drugs and
medications, including nicotine patches
° Diet pills or appetite
suppressants (except when used in the treatment of
morbid obesity)
° Replacement of drugs due to loss or theft
° Prescriptions
more than one year from the original date of issue
° Injectable
fertility drugs (see Infertility benefit under Medical and Surgical Benefits for
limited coverage)
Retail Pharmacy
$ 5 per generic drug.
$15 per name brand drug.
Mail Order
$10 per generic drug.
$40 per name brand drug.
Note: If there is no generic equivalent available, you
will still have to
pay the brand name copay. 29
29 Page 30 31
30 2001 CIGNA
HealthCare of Arizona, Inc.
Special Features
Under the
flexible benefits option, we determine the most effective way to provide
services.
° We may identify medically appropriate alternatives to
traditional care and coordinate other benefits as a less costly alternative
benefit.
° Alternative benefits are subject to our ongoing review.
° By approving an alternative benefit, we cannot guarantee you will get
it in the future.
° The decision to offer an alternative benefit is solely ours, and we may
withdraw it at any time and resume regular contract benefits.
° Our
decision to offer or withdraw alternative benefits is not subject to OPM review
under the disputed claims process.
For any of your health concerns, 24 hours a day, 7 days a week, you may call
1-800-832-3211 and talk with a registered nurse who will discuss
treatment
options and answer your health questions.
We provide a TDD line for the deaf
and hearing impaired in addition to the use of the state relay line.
Healthy Babies is a program that provides guidance and support to women from
pre-pregnancy through post-partum care. This program is
designed to promote
better maternity care, reduce the number of premature births and educate
expectant parents.
CIGNA HealthCare members have access to the CIGNA Lifesource Organ Transplant
Network ® which is an organization of participating
hospitals which
provides organ transplant services. As part of the rigorous credentialing
program, each hospital's transplant program is
evaluated for patient
outcome, as well as waiting period, housing arrangements, "patient
friendly" environment and the availability of
transportation, before it
is included in the CIGNA Lifesource Organ Transplant Network ® .
The information you need Ð instantly, easily and online. Our web site
helps you find answers for your questions. You can search for
participating
providers, refill your Tel-Drug prescriptions, change your PCP, read online
health and wellness publications, or send us an e-mail.
Visit our national
web site at www. cigna. com/ healthcare and explore to learn more.
We cover you for emergency services anywhere in the world!
Description Feature
Flexible benefits option
24 hour nurse line
Services for deaf and hearing impaired
High
risk pregnancies
Centers of Excellence for transplants/ heart surgery/
etc.
Internet access
Travel benefit / services overseas
Section 5( g)
Section 5 (g). 30
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31 2001 CIGNA
HealthCare of Arizona, Inc.
Dental benefits Section 5 (h).
Section 5( h)
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You pay Benefit Description
Accidental injury benefit
We cover
restorative services and supplies necessary to promptly repair $10 per office
visit (but not replace) sound natural teeth. The need for these services must
result
from an accidental injury.
Here are some important things to keep in mind about these benefits:
° Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are
medically necessary.
° Plan dentists must provide or arrange your
care.
° We have no calendar year deductible.
° We cover
hospitalization for dental procedures only when prior authorized by the Plan
Medical Director and a non-dental physical impairment exists which makes
hospitalization necessary to safeguard the health of the patient; we do not
cover the dental procedure unless it is described below. Be sure to read Section
4, Your costs
for covered services for valuable information about how
cost sharing works. Also
read Section 9 about coordinating benefits with
other coverage, including with Medicare.
Dental benefits
We have no other dental benefits. 31
31 Page 32 33
32 2001 CIGNA HealthCare of Arizona, Inc. Section
5( i)
Non-FEHB benefits available to Plan members Section 5 (i).
The benefits on this page are not part of the FEHB contract or premium,
and you cannot file an FEHB disputed claim about them. Fees you pay for
these services do not count toward FEHB deductibles or out-of-pocket
maximums.*
Guest Privileges
If you or a covered family member
temporarily moves outside of the service area for at least 90 days, you may be
eligible for the Plan's "guest privileges" program. The "guest
privileges" program allows participants to enroll as
"guests" in another CIGNA HealthCare site. This program is only
available when you or your covered family member is temporarily relocating to an
approved CIGNA guest site. Guest privileges is an ideal way to arrange
for
benefits in situations such as: temporary job transfer/ work assignments;
college child attending school away from home, etc. You should be aware that
your FEHBP benefits will NOT follow you to the guest site. You will
be
covered by the CIGNA HealthCare "guest privileges" program plan of
benefits. Contact member services at 1-800-832-3211 for more information.
Alternative Care
We offer a variety of health education classes
including Tai Chi. Additionally, through vendor arrangements, our members are
entitled to discounts on vitamins and supplements as well as massage therapy.
Birthday Card Reminders
We understand that people are very busy
and might forget important things like childhood immunizations and mammography
screenings. So, we send reminders to all women and children on our Plan to make
sure we see
them for this and other preventive care.
Direct Access to OB/ GYN
Women may choose to see a contracted OB/ GYN for covered services
without a referral from their PCP.
Member Service Hours
We have extensive Member Services hours to
serve you. A friendly representative is available to assist you from 7: 00 am to
9: 00 pm, Monday through Friday; 8: 00 am to 5: 00 pm on Saturday.
Wellness Classes
We offer classes for children, adults and
seniors. Instruction is provided by professionally trained educators on topics
ranging from nutrition to stress management.
Well-Being Stay current with your healthplan benefits and programs. We
mail our members a health and wellness newsletter
three times per year.
Well-being includes reminders about preventive care, quality programs,
tips for using your health coverage and information on topics important to help
you lead a healthy life.
Medicare prepaid plan enrollment
This plan offers Medicare
recipients the opportunity to enroll in the Plan through Medicare. As indicated
on page 39, annuitants and former spouses with FEHB coverage and with Medicare
Part B may elect to drop their
FEHB coverage and enroll in a Medicare prepaid plan when one is available in
their area. They may then later reenroll in the FEHBP Program. Most Federal
annuitants have Medicare Part A. Those without Medicare Part A
may join this
Medicare prepaid plan but will probably have to pay for hospital coverage in
addition to the Part B premium. Before you join the plan, ask whether the plan
covers hospital benefits and, if so, what you will have to
pay. Contact your
retirement system for information on dropping your FEHB enrollment and changing
to a Medicare prepaid plan. Contact us at 1-800-430-0768 for information on the
Medicare prepaid plan and the cost
of that enrollment.
* This program is provided for the benefit of CIGNA members and is not an
endorsement of the services or vendors listed. 32
32 Page 33 34
33 2001 CIGNA HealthCare of Arizona, Inc. Section 6
General exclusions Ð things we don't cover Section 6.
The
exclusions in this section apply to all benefits. Although we may list a
specific service as a benefit, we will not cover it unless your Plan doctor
determines it is medically necessary to prevent, diagnose, or treat your
illness, disease, injury, or condition and we agree, as discussed under
Services requiring our prior approval on page 10.
We do not cover the following:
° Care by non-Plan providers except
for authorized referrals or emergencies (see Emergency Benefits);
° Services, drugs, or supplies you receive while you are not
enrolled in this Plan;
° Services, drugs, or supplies that are not
medically necessary;
° Services, drugs, or supplies not required
according to accepted standards of medical, dental, or psychiatric practice;
° Experimental or investigational procedures, treatments, drugs or
devices;
° Services, drugs, or supplies related to abortions, except
when the life of the mother would be endangered if the fetus were carried to
term or when the pregnancy is the result of an act of rape or incest;
° Services, drugs, or supplies related to sex transformations; or
° Services, drugs, or supplies you receive from a provider or facility
barred from the FEHB Program. 33
33 Page 34 35
34 2001 CIGNA
HealthCare of Arizona, Inc. Section 7
Filing a claim for covered
services Section 7.
When you see Plan physicians, receive services at
Plan hospitals and facilities, or obtain your prescription drugs at Plan
pharmacies, you will not have to file claims. Just present your identification
card and pay your copayment.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these providers bill us directly. Check with the
provider. If you need to file the claim, here is the process:
In most cases, providers and facilities file claims for you. Physicians must
file on the form HCFA-1500, Health Insurance Claim Form. Facilities will
file on the UB-92 form. For claims questions and assistance, call us at
1-800-832-3211.
When you must file a claim Ñ such as for out-of-area care Ñ
submit it on the HCFA-1500 or a claim form that includes the information shown
below.
Bills and receipts should be itemized and show:
° Covered
member's name and ID number;
° Name and address physician or facility
that provided the service or supply;
° Dates you received the services or supplies;
° Diagnosis;
° Type of each service or supply;
° The charge for each service
or supply;
° A copy of the explanation of benefits, payments, or denial
from any primary payer Ñ such as the Medicare Summary Notice (MSN); and
° Receipts, if you paid for your services.
Submit your claims to:
Please refer to your ID card for the address to mail any claims.
Send us all of the documents for your claim as soon as possible. You must
submit the claim by December 31st of the year after the year you
received
the service, unless timely filing was prevented by administrative operations of
Government or legal incapacity, provided the claim was
submitted as soon as
reasonably possible.
Please reply promptly when we ask for additional information. We may delay
processing or deny your claim if you do not respond.
Medical, hospital and drug benefits
Deadline for filing your claim
When we need more information 34
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35 2001 CIGNA
HealthCare of Arizona, Inc.
Ask us in writing to reconsider our initial
decision. Write to us at: CIGNA HealthCare of Arizona, Inc., 11001 N. Black
Canyon Hwy, Suite 400, Phoenix, AZ 85029. You must:
(a) Write to us within 6
months from the date of our decision; and
(b) Send your request to us at:
CIGNA HealthCare of Arizona, Inc., 11001 N. Black Canyon Hwy., Suite 400,
Phoenix, AZ 85029; and
(c) Include a statement about why you believe our initial decision was wrong,
based on specific benefit provisions in this brochure; and
(d) Include
copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical records, and explanation of benefits (EOB)
forms.
We have 30 days from the date we receive your request to:
(a) Pay the
claim (or, if applicable, arrange for the health care provider to give you the
care); or
(b) Write to you and maintain our denial Ñ go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider,
we will send you a copy of our request. Go to step 3.
You or your provider must send the information so that we receive it within
60 days of our request. We will then decide within 30 more days.
If we do
not receive the information within 60 days, we will decide within 30 days of the
date the information was due. We will base our decision on the information we
already have.
We will write to you with our decision.
If you do not
agree with our decision, you may ask OPM to review it.
You must write to OPM
within:
° 90 days after the date of our letter upholding our initial decision; or
° 120 days after you first wrote to us Ñ if we did not answer
that request in some way within 30 days; or
° 120 days after we asked for additional information.
Write to OPM
at: Office of Personnel Management, Office of Insurance Programs, Contracts
Division III, P. O. Box 436, Washington, D. C. 20044-0436.
Send OPM the following information:
° A statement about why you
believe our decision was wrong, based on specific benefit provisions in this
brochure;
° Copies of documents that support your claim, such as physicians'
letters, operative reports, bills, medical records, and explanation of benefits
(EOB) forms;
° Copies of all letters you sent to us about the claim;
° Copies of all letters we sent to you about the claim; and
°
Your daytime phone number and the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to which claim.
The disputed claims process Section 8.
Follow this Federal
Employees Health Benefits Program disputed claims process if you disagree with
our decision on your claim or request for services, drugs, or supplies Ð
including a request for preauthorization:
Step Description
1
Section 8
2
3
4 35
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36 2001 CIGNA HealthCare of
Arizona, Inc.
Note: You are the only person who has a right to file a
disputed claim with OPM. Parties acting as your representative, such as medical
providers, must provide a copy of your specific written consent
with the
review request.
Note: The above deadlines may be extended if you show that
you were unable to meet the deadline because of reasons beyond your control.
OPM will review your disputed claim request and will use the information it
collects from you and us to decide whether our decision is correct. OPM will
send you a final decision within 60 days.
There are no other administrative
appeals.
If you do not agree with OPM's decision, your only recourse is to sue. If you
decide to sue, you must file the suit against OPM in Federal court by December
31 of the third year after the year in
which you received the disputed
services, drugs, or supplies. This is the only deadline that may not be
extended.
OPM may disclose the information it collects during the review process to
support their disputed claim decision. This information will become part of the
court record.
You may not sue until you have completed the disputed claims
process. Further, Federal law governs your lawsuit, benefits, and payment of
benefits. The Federal court will base its review on the record
that was
before OPM when OPM decided to uphold or overturn our decision. You may recover
only the amount of benefits in dispute.
NOTE: If you have a serious or life threatening conditions (one that
may cause permanent loss of bodily functions or death if not treated as soon as
possible), and
(a) We haven't responded yet to your initial request for care
or preauthorization/ prior approval, then call us at 1-800-832-3211 and we will
expedite our review; or
(b) We denied your initial request for care or
preauthorization/ prior approval, then:
° ° If we expedite our
review and maintain our denial, we will inform OPM so that they can give your
claim expedited treatment too, or
° ° You can call OPM's Health Benefits Contracts Division III at
202-606-0737 between 8 a. m. and 5 p. m. eastern time.
5
6
Section 8
The disputed claims process (CONTINUED) 36
36 Page 37 38
37 2001 CIGNA HealthCare of Arizona, Inc. Section 9
Coordinating benefits with other coverage Section 9.
When you
have other
health coverage
You must tell us if you are covered or a family
member is covered under another group health plan or have automobile insurance
that pays health
care expenses without regard to fault. This is called
"double coverage."
When you have double coverage, one plan
normally pays its benefits in full as the primary payer and the other plan pays
a reduced benefit as the
secondary payer. We, like other insurers, determine which coverage is primary
according to the National Association of Insurance Commissioners'
guidelines.
When we are the primary payer, we will pay the benefits
described in this brochure.
When we are the secondary payer, we will determine our allowance. After the
primary plan pays, we will pay what is left of our allowance, up
to our
regular benefit. We will not pay more than our allowance.
Medicare is a Health Insurance Program for:
° ° People 65 years
of age and older.
° ° Some people with disabilities, under 65 years
of age.
° ° People with End-Stage Renal Disease (permanent kidney
failure requiring dialysis or a transplant).
Medicare has two parts:
° ° Part A (Hospital Insurance). Most
people do not have to pay for Part A.
° ° Part B (Medical
Insurance). Most people pay monthly for Part B.
If you are eligible for Medicare, you may have choices in how you get your
health care. Medicare + Choice is the term used to describe the various
health plan choices available to Medicare beneficiaries. The information in
the next few pages shows how we coordinate benefits with Medicare,
depending
on the type of Medicare managed care plan you have.
The Original Medicare Plan is available everywhere in the United States. It
is the way most people get their Medicare Part A and Part B benefits.
You
may go to any doctor, specialist, or hospital that accepts Medicare. Medicare
pays its share and you pay your share. Some things are not
covered under
Original Medicare, like prescription drugs.
When you are enrolled in this
Plan and Original Medicare, you still need to follow the rules in this brochure
for us to cover your care. Your care must
continue to be authorized by your Plan PCP, or recertified as required.
We will not waive any of our copayments or coinsurance.
° What is Medicare?
° The Original Medicare Plan
(Primary
payer chart begins on next page) 37
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38 2001 CIGNA
HealthCare of Arizona, Inc.
4
(for Part B services)
Section 9
Primary Payer Chart
Then the primary payer is . . . A. When either you
Ð or your covered spouse Ð are age 65 or over and . . .
Original
Medicare This Plan
(except for claims related
to Workers' Compensation)
4
(for other services)
The following chart illustrates whether Original Medicare or this Plan should
be the primary payer for you according
to your employment status and other
factors determined by Medicare. It is critical that you tell us if you or a
covered
family member has Medicare coverage so we can administer these
requirements correctly.
1) Are an active employee with the Federal government (including when you or
a family member are eligible for Medicare solely because of a disability),
2) Are an annuitant,
3) Are a reemployed annuitant with the Federal
government when
a) The position is excluded from FEHB, or
................................................
b) The position is not
excluded from FEHB ...............................................
Ask your
employing office which of these applies to you.
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court
judge who retired under Section 7447 of title 26, U. S. C. (or if your
covered spouse is this type of judge),
5) Are enrolled in Part B only, regardless of your employment status,
6) Are a former Federal employee receiving Workers' Compensation and the
Office of Workers' Compensation Programs has determined that you are
unable
to return to duty,
B. When you Ñ or a covered family member Ñ have Medicare
based on end stage renal disease (ESRD) and . . .
1) Are within the
first 30 months of eligibility to receive Part A benefits solely because of
ESRD,
2) Have completed the 30-month ESRD coordination period and are still
eligible for Medicare due to ESRD,
3) Become eligible for Medicare due to
ESRD after Medicare became primary for you under another provision,
C.
When you or a covered family member have FEHB and . . .
1) are eligible
for Medicare based on disability, and
a) Are an annuitant, or
.................................................................................
b) Are an active employee
........................................................................... 4
4
4
4
4
4
4
4
4
4
4 38
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39 2001 CIGNA HealthCare of
Arizona, Inc.
If you are eligible for Medicare, you may choose to enroll
in and get your Medicare benefits from a Medicare managed care plan. These are
health
care choices (like HMOs) in some areas of the country. In most
Medicare managed care plans, you can only go to doctors, specialists, or
hospitals that
are part of the plan. Medicare managed care plans cover all
Medicare Part A and B benefits. Some cover extras, like prescription drugs. To
learn more
about enrolling in a Medicare managed care plan, contact Medicare
at 1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov. If you
enroll
in a Medicare managed care plan, the following options are available to you:
This Plan and our Medicare managed care plan: You may enroll in our
Medicare managed care plan and also remain enrolled in our FEHB plan. In
this case, we do not waive any of our copayments, coinsurance, or
deductibles for your FEHB coverage.
This Plan and another Plan's Medicare managed care plan: You may
enroll in another plan's Medicare managed care plan and also remain
enrolled
in our FEHB plan. We will still provide benefits when your Medicare managed care
plan is primary, even out of the managed care
plan's network and/ or service
area (if you use our Plan providers), but we will not waive any of our
copayments, coinsurance, or deductibles.
Suspended FEHB coverage and a Medicare managed care plan: If you are
an annuitant or former spouse, you can suspend your FEHB coverage to
enroll
in a Medicare managed care plan, eliminating your FEHB premium. (OPM does not
contribute to your Medicare managed care plan premium.)
For information on
suspending your FEHB enrollment, contact your retirement office. If you later
want to re-enroll in the FEHB Program,
generally you may do so only at the
next open season unless you involuntarily lose coverage or move out of the
Medicare+ Choice service area.
Note: If you choose not to enroll in Medicare Part B, you can still be
covered under the FEHB Program. We cannot require you to enroll in
Medicare.
TRICARE is the health care program for eligible dependents of military
persons and retirees of the military. TRICARE includes the CHAMPUS
program.
If both TRICARE and this Plan cover you, we pay first. See your TRICARE Health
Benefits Advisor if you have questions about TRICARE
coverage.
° Enrollment in Medicare Part B
° Medicare managed care plan
Section 9
TRICARE
Claims process Ñ You probably will never have to file a claim
form when you have both our Plan and Medicare. Please note, if
your Plan
physician does not participate in Medicare, you will have to file a claim with
Medicare.
° When we are the primary payer, we process the claim first.
°
When Original Medicare is the primary payer, Medicare
processes your claim
first. In most cases, your claims will be coordinated automatically and we will
pay the balance
of covered charges. You will not need to do anything. In this case we do not
waive any out-of-pocket costs. To find
out if you need to do something about
filing your claims, call us at 1-800-832-3211, or write to CIGNA HealthCare
of Arizona, Inc., 11001 N. Black Canyon Hwy., Suite 400, Phoenix, AZ 85029.
You may also visit our website at
www. cigna. com/ healthcare. 39
39 Page 40 41
40 2001 CIGNA HealthCare of Arizona, Inc.
Medicaid
When other Government Agencies are responsible
for
your care
When others are responsible for injuries
Section 9
Workers' Compensation
We do not cover services that:
° you need because of a workplace-related disease or injury that the
Office of Workers' Compensation Programs (OWCP) or a similar Federal or
State agency determines they must provide; or
° OWCP or a similar
agency pays for through a third party injury settlement or other similar
proceeding that is based on a claim you filed
under OWCP or similar laws.
Once OWCP or similar agency pays its maximum
benefits for your treatment, we will cover your benefits. You must use our
providers.
When you have this Plan and Medicaid, we pay first.
We do not cover
services and supplies when a local, State, or Federal Government agency directly
or indirectly pays for them.
When you receive money to compensate you for medical or hospital care for
injuries or illness caused by another person, you must reimburse us for any
expenses we paid. However, we still cover the cost of treatment that exceeds
the amount you received in the settlement.
If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our subrogation
procedures. 40
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41 42
41 2001 CIGNA HealthCare of
Arizona, Inc.
Definitions of terms we use in this brochure Section
10.
January 1 through December 31 of the same year. For new enrollees,
the calendar year begins on the effective date of their enrollment and ends on
December 31 of the same year.
A copayment is a fixed amount of money you
pay when you receive covered services. See page 11.
Care we provide benefits for, as described in this brochure.
A deductible
is a fixed amount of covered expenses you must incur for certain covered
services and supplies before we start paying benefits for
those services. See page 11.
Experimental, investigational and unproven
services are medical, surgical, diagnostic, psychiatric, substance abuse or
other health care technologies,
supplies, treatments, procedures, drug therapies or devices that are
determined by the Healthplan Medical Director to be:
° not approved by the U. S. Food and Drug Administration (FDA) to be
lawfully marketed for the proposed use and not recognized for the
treatment
of the particular indication in one of the standard reference compendia (The
United States Pharmacopoeia Drug Information, The
American Medical
Association Drug Evaluations; or the American Hospital Formulary Service Drug
Information) or in medical literature.
Medical literature means scientific
studies published in a peer-reviewed national professional medical journal;
° the subject of review or approval by an Institutional Review Board for
the proposed use;
° the subject of an ongoing clinical trial that meets
the definition of a phase I, II or III Clinical Trial as set forth in the FDA
regulations, regardless of
whether the trial is subject to FDA oversight; or
° not demonstrated, through existing peer-reviewed literature to be safe
and effective for treating or diagnosing the condition or illness for which its
use is proposed.
Medically necessary covered Services and Supplies are
those Services and Supplies that are determined by the Healthplan Medical
Director to be:
° No more than required to meet your basic health needs; and
°
consistent with the diagnosis of the condition for which they are required; and
° consistent in type, frequency and duration of treatment with
scientifically based guidelines as determined by medical research; and
°
required for purposes other than the comfort and convenience of the patient or
his Physician; and
° rendered in the least intensive setting that is
appropriate for the delivery of health care; and
° of demonstrated
medical value.
Us and we refer to CIGNA HealthCare of Arizona, Inc.
You
refers to the enrollee and each covered family member.
Section 10
Calendar year
Copayment
Covered services
Deductible
Experimental or investigational services
Medical necessity
Us/ We
You 41
41
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2001 CIGNA HealthCare of Arizona, Inc. Section 11
FEHB facts
Section 11.
We will not refuse to cover the treatment of a condition
that you had before you enrolled in this Plan solely because you had the
condition before you enrolled.
See www. opm. gov/ insure. Also, your employing or retirement office can
answer your questions, and give you a Guide to Federal Employees Health
Benefits Plans, brochures for other plans, and other materials you need
to make
an informed decision about:
° When you may change your enrollment;
° How you can cover your
family members;
° What happens when you transfer to another Federal
agency, go on leave without pay, enter military service, or retire;
° When your enrollment ends; and
° When the next open season for
enrollment begins.
We don't determine who is eligible for coverage and, in
most cases, cannot change your enrollment status without information from your
employing or
retirement office.
Self Only coverage is for you alone. Self and Family
coverage is for you, your spouse, and your unmarried dependent children under
age 22, including any
foster children or stepchildren your employing or
retirement office authorizes coverage for. Under certain circumstances, you may
also continue coverage for
a disabled child 22 years of age or older who is
incapable of self-support.
If you have a Self Only enrollment, you may
change to a Self and Family enrollment if you marry, give birth, or add a child
to your family. You may
change your enrollment 31 days before to 60 days after that event. The Self
and Family enrollment begins on the first day of the pay period in which the
child is born or becomes an eligible family member. When you change to Self
and Family because you marry, the change is effective on the first day of the
pay period that begins after your employing office receives your enrollment
form; benefits will not be available to your spouse until you marry.
Your employing or retirement office will not notify you when a family
member is no longer eligible to receive health benefits, nor will we. Please
tell us im-mediately
when you add or remove family members from your
coverage for any reason, including divorce, or when your child under age 22
marries or turns 22.
If you or one of your family members is enrolled in one FEHB plan, that
person may not be enrolled in or covered as a family member by another
FEHB
plan.
The benefits in this brochure are effective on January 1. If you are
new to this Plan, your coverage and premiums begin on the first day of your
first pay period
that starts on or after January 1. Annuitants' premiums
begin on January 1.
We will keep your medical and claims information
confidential. Only the following will have access to it:
° OPM, this Plan, and subcontractors when they administer this contract;
° This Plan, and appropriate third parties, such as other insurance
plans and the Office of Workers' Compensation Programs (OWCP), when coordinating
benefit payments and subrogating claims;
° Law enforcement officials
when investigating and/ or prosecuting alleged civil or criminal actions;
No pre-existing condition limitation
Where you can get information
about
enrolling in the FEHB Program
Types of coverage available for you
and your family
When benefits and premiums start
Your medical and claims records are
confidential 42
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43 2001 CIGNA HealthCare of
Arizona, Inc. Section 11
When you retire
When you lose benefits
° When FEHB coverage ends
° Spouse equity coverage
° TCC
° Converting to individual coverage
° OPM and the General Accounting Office when conducting audits;
°
Individuals involved in bona fide medical research or education that does not
disclose your identity; or
° OPM, when reviewing a disputed claim or defending litigation about a
claim.
When you retire, you can usually stay in the FEHB Program. Generally,
you must have been enrolled in the FEHB Program for the last five years of your
Federal service. If you do not meet this requirement, you may be eligible
for other forms of coverage, such as Temporary Continuation of Coverage
(TCC).
You will receive an additional 31 days of coverage, for no
additional premium, when:
° ° Your enrollment ends, unless you cancel your enrollment, or
° ° You are a family member no longer eligible for coverage.
You
may be eligible for spouse equity coverage or Temporary Continuation of
Coverage.
If you are divorced from a Federal employee or annuitant, you may not
continue to get benefits under your former spouse's enrollment. But, you
may
be eligible for your own FEHB coverage under the spouse equity law. If you are
recently divorced or are anticipating a divorce, contact your
ex-spouse's
employing or retirement office to get RI 70-5, the Guide to Federal Employees
Health Benefits Plans for Temporary Continuation of
Coverage and Former
Spouse Enrollees, or other information about your coverage choices.
If you leave Federal service, or if you lose coverage because you no longer
qualify as a family member, you may be eligible for Temporary Continua-tion
of Coverage (TCC). For example, you can receive TCC if you are not able to
continue your FEHB enrollment after you retire.
You may not elect TCC if you are fired from your Federal job due to gross
misconduct.
Get the RI 79-27, which describes TCC, and the RI 70-5, the
Guide to Federal Employees Health Benefits Plans for Temporary Continuation
of
Coverage and Former Spouse Enrollees, from your employing or
retirement
office or from www. opm. gov/ insure.
You may convert to a non-FEHB individual policy if:
° ° Your
coverage under TCC or the spouse equity law ends. If you canceled your coverage
or did not pay your premium, you cannot
convert;
° ° You decided not to receive coverage under TCC or the
spouse equity law; or
° ° You are not eligible for coverage under TCC or the spouse equity
law.
If you leave Federal service, your employing office will notify you of
your right to convert. You must apply in writing to us within 31 days after you
receive this notice. However, if you are a family member who is losing
coverage, the employing or retirement office will not notify you. You
must
apply in writing to us within 31 days after you are no longer eligible
for coverage.
Your benefits and rates will differ from those under the FEHB Program;
however, you will not have to answer questions about your health, and we
will not impose a waiting period or limit your coverage due to pre-existing
conditions. 43
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44 2001 CIGNA HealthCare of
Arizona, Inc. Section 11
Inspector General Advisory
Penalties for
Fraud
Getting a Certificate of Group Health Plan
Coverage
If you
leave the FEHB Program, we will give you a Certificate of Group Health Plan
Coverage that indicates how long you have been enrolled with
us. You can use
this certificate when getting health insurance or other health care coverage.
Your new plan must reduce or eliminate waiting periods,
limitations, or
exclusions for health related conditions based on the information in the
certificate, as long as you enroll within 63 days of losing
coverage under
this Plan.
If you have been enrolled with us for less than 12 months, but
were previously enrolled in other FEHB plans, you may also request a certificate
from those plans.
Stop health care fraud! Fraud increases the cost
of health care for everyone. If you suspect that a physician, pharmacy, or
hospital has charged
you for services you did not receive, billed you twice
for the same service, or misrepresented any information, do the following:
° Call the provider and ask for an explanation. There may be an error.
° If the provider does not resolve the matter, call us at 1-800-832-3211
and explain the situation.
° If we do not resolve the issue, call THE HEALTH CARE FRAUD HOTLINE
Ñ 202-418-3300 or write to: The United States Office of
Personnel
Management, Office of the Inspector General Fraud Hotline, 1900 E Street, NW,
Room 6400, Washington, DC 20415.
Anyone who falsifies a claim to obtain FEHB Program benefits can be
prosecuted for fraud. Also, the Inspector General may investigate anyone
who
uses an ID card if the person tries to obtain services for someone who is not an
eligible family member, or is no longer enrolled in the Plan and
tries to
obtain benefits. Your agency may also take administrative action against you. 44
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45 2001 CIGNA HealthCare of Arizona, Inc.
Accidental injury ............................ 31
Allergy
tests .................................... 15
Alternative treatment
...................... 18
Ambulance ......................................
23
Anesthesia ...................................... 21
Autologous bone
marrow transplant ........................ 21
Biopsies
......