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SUMMARY OF BENEFITS Connecticut General Life Insurance Co.
Long Island University – Buy-Up 2
Preferred Provider Organization Copay Plan
Annual deductibles and maximums
In-network
Out-of-network
Lifetime maximum
Pre-Existing Condition Limitation (PCL)
Coinsurance
Maximum reimbursable charge
• Determined based on the lesser of:
• the health care professional’s normal charge for • a percentile of the amount charged by health care professionals in the geographic area where • Out-of-network services are subject to a calendar year deductible and maximum reimbursable charge limitations. Calendar year deductible
• The amount you pay for out-of-network services
counts towards both your in-network and out-of- network deductibles. (One way accumulation) Employee
Employee
• After each family member meets his or her individual Employee and family
deductible, the plan will pay his or her claims, less Employee and family
any coinsurance amount. After the family deductible has been met, each individual’s claims will be paid by the plan, less any coinsurance amount. Calendar year out-of-pocket maximum
• The amount you pay for out-of-network services
counts towards both your in-network and out-of-network out-of-pocket maximums. (One way accumulation) • Medical /Pharmacy combined • Deductibles do not contribute toward the out-of- Per Person
Per Person
Copays do not contribute towards the out-of-pocket Mental health and substance abuse services count • After each family member meets his or her individual out-of-pocket maximum, the plan will pay 100% of their covered expenses. After the family out-of-pocket maximum has been met, the plan will pay 100% of each individual’s covered expenses. Long Island University
Preferred Provider Organization Copay Plan
Benefits
In-network
Out-of-network
Physician services
Office visit
Physician services (hospital)
Inpatient and outpatient
services
Surgery (in a physician’s office)
Preventive care
Routine preventive care
• Includes well-baby, well-child, well-woman and
In-network immunizations are covered at no Mammogram, PSA, Pap Smear and Maternity
Screening
• Coverage includes the associated Preventive
• Diagnostic-related services are covered at the same level of benefits as other x-ray and lab services, based on place of service. Inpatient hospital facility services
Semi-private room and board and other non-
physician services
• Inpatient room and board, pharmacy, x-ray, lab, Private room stays may result in extra charges Inpatient Professional Services
For services performed by surgeons, radiologists, Multiple surgical reduction
• Multiple surgeries performed during one operating session result in payment reduction of 50% to the surgery of lesser charge. The most expensive procedure is paid as any other surgery. Outpatient services
Outpatient surgery (facility charges)
• Non-surgical treatment procedures are not subject to the facility copay/deductible. Long Island University
Preferred Provider Organization Copay Plan
Benefits
In-network
Out-of-network
Outpatient Professional Services
For services performed by surgeons, radiologists, Physical, occupational, cognitive and speech
therapy
• Unlimited days per calendar year for all therapies
• Includes physical therapy, speech therapy, occupational therapy, pulmonary rehabilitation • Therapy days, provided as part of an approved Home Health Care plan, accumulate to the outpatient short term rehab therapy maximum. Chiropractic care
Acupuncture
Lab and X-ray
Lab and X-ray
Lab and X-ray
Lab and X-ray, emergency room and urgent care
• Emergency room when billed by the facility as
Urgent care when billed by the facility as part of • Independent x-ray and/or lab facility in Advanced radiological imaging
(MRI, MRA, CAT Scan, PET Scan, etc.)
Advanced radiological imaging
(MRI, MRA, CAT Scan, PET Scan, etc.)
Advanced radiological imaging
(MRI, MRA, CAT Scan, PET Scan, etc.)
Long Island University
Preferred Provider Organization Copay Plan
Benefits
In-network
Out-of-network
Emergency and urgent care services
Hospital emergency room
• Includes radiology, pathology and physician
Copay waived if admitted, then inpatient hospital • Out-of-network services are covered at the in- Ambulance
• Out-of-network services are covered the same as
Note: Non-emergency transportation (e.g. from hospital back home) is generally not covered. Urgent care services
• Out-of-network services are covered at the in-
Copay waived if admitted, then inpatient hospital Other health care facilities
Skilled nursing facility, rehabilitation hospital and
other facilities
Home health care
Other health care services
Durable medical equipment
External prosthetic appliances (EPA)
TMJ, surgical and non-surgical
Long Island University
Preferred Provider Organization Copay Plan
Benefits
In-network
Out-of-network
Infertility
• Office visit for testing, treatment \
• Inpatient hospital facility
•
Surgical treatment limited to procedures to • Artificial insemination - Unlimited • In-vitro, GIFT, ZIFT, etc. - $10,000 Lifetime Max Family planning
• Inpatient hospital facility
•
Surgical services such as tubal ligation or vasectomy are covered (excluding reversals). • Does not include contraceptive devices Mental health and substance abuse services
Please note the following regarding Mental Health (MH) and Substance Abuse (SA) benefit administration: • Substance Abuse includes Alcohol and Drug Abuse services. • Transition of Care benefits are provided for a 90-day time period. Inpatient mental health services
•
Mental health services are paid at 100% after you Outpatient mental health physician’s office services
• Unlimited visits per calendar year
• Mental health and substance abuse services are paid at 100% after you reach your out-of-pocket Inpatient substance abuse services
• Substance abuse services are paid at 100% after Outpatient substance abuse - physician’s office
services
•
Mental health and substance abuse services are paid at 100% after you reach your out-of-pocket maximum. Prescription drugs
CIGNA Pharmacy single tier coinsurance plan
• Self administered injectable– excludes infertility • Lifestyle drugs – limited to sexual dysfunction Home Delivery
Long Island University
Preferred Provider Organization Copay Plan
Benefits
In-network
Out-of-network
Pharmacy Clinical Management and Prior Authorization
• Your plan is subject to certain clinical edits and prior authorization requirements. Specialty Pharmacy
• Clinical Programs
Prior authorization required on specialty medications and quantity limits may apply. Medication Access Option: Retail and/or Home Delivery Vision care
Long Island University
Preferred Provider Organization Copay Plan
Definitions
Deductible – A flat dollar amount you must pay out of your own pocket before your plan begins to pay for covered
services.
Coinsurance – After you’ve reached your deductible, you and your plan share some of your medical costs. The portion of
covered expenses you are responsible for is called coinsurance.
Copay – A flat fee you pay for certain covered services such as doctor’s visits or prescriptions.
Out-of-pocket Maximum – Specific limits for the total amount you will pay out of your own pocket before your plan
coinsurance percentage no longer applies. Once you meet these maximums, your plan then pays 100 percent of the
“maximum reimbursable charges” or negotiated fees for covered services.
Place of service – Your plan pays based on where you receive services. For example, for hospital stays, your coverage
is paid at the inpatient level.
Selection of a Primary Care Provider – Your plan may require or allow the designation of a primary care provider. You
have the right to designate any primary care provider who participates in the network and who is available to accept you
or your family members. If your plan requires designation of a primary care provider, CIGNA may designate one for you
until you make this designation. For information on how to select a primary care provider, and for a list of the participating
primary care providers, visit www.mycigna.com or contact customer service at the phone number listed on the back of
your ID card.
For children, you may designate a pediatrician as the primary care provider. Direct Access to Obstetricians and Gynecologists – You do not need prior authorization from the plan or from any
other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a
health care professional in our network who specializes in obstetrics or gynecology. The health care professional,
however, may be required to comply with certain procedures, including obtaining prior authorization for certain services,
following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care
professionals who specialize in obstetrics or gynecology, visit www.mycigna.com or contact customer service at the
phone number listed on the back of your ID card.
Transition of Care – Provides in-network health coverage to new customers when the customer’s doctor is not part of the
CIGNA network and there are approved clinical reasons why the customer should continue to see the same doctor.
Maximizing your health care dollars
Log on to myCIGNA.com for resources to help you choose a health care professional or compare the cost and quality of medical services, medications and hospital care. When you need a medical service or procedure, CIGNA offers you opportunities to save on prescription medicine, routine medical care, laboratory services, radiology scans, and outpatient surgery. Details are below: CIGNA Home Delivery Pharmacy –You can save money and enjoy convenient home delivery by using CIGNA Home
Delivery Pharmacy for your prescription medications. You can get up to a 90-day supply of your medication.
Lab – Save on lab services by using a free-standing laboratory instead of a hospital- or clinic-based lab.
Urgent Care – For non-emergency conditions that need attention before you can see your doctor, you can save money
by going to an urgent care center instead of an Emergency Room (ER).
Convenience Care – For minor or routine conditions, go to a Convenience Care Clinic when your doctor is unavailable.
Convenience Care Clinics are retail-based and often found in pharmacies or grocery stores.
Radiology – Costs for MRIs, PET, and CT scans can vary greatly. Non-hospital based outpatient radiology centers often
cost much less than a hospital. CIGNA's network includes both hospitals and outpatient centers, so you can find a
radiology center that’s right for you.
Outpatient Surgery – Costs for colonoscopies, arthroscopies, and other outpatient procedures can vary greatly. Using a
free-standing outpatient surgery center can save hundreds of dollars.
Long Island University
Preferred Provider Organization Copay Plan
Exclusions
What’s Not Covered (not all-inclusive):
Your plan provides coverage for most medically necessary services. Examples of things your plan does not cover, unless required by law or covered under the pharmacy benefit, include (but aren’t limited to): • Services provided through government programs • Services that aren’t medically necessary • Experimental, investigational or unproven services • Services for an injury or illness that occurs while working for pay or profit including services covered by workers’ • Cosmetic services • Dental care, unless due to accidental injury to sound natural teeth • Reversal of sterilization procedures • Genetic screenings • Non-prescription and anti-obesity drugs • Custodial and other non-skilled services • Weight loss programs • Treatment of sexual dysfunction • Travel immunizations • Telephone, email and internet consultations in the absence of a specific benefit • Eyeglass lenses and frames, contact lenses and surgical vision correction
These are only the highlights
This summary outlines the highlights of your plan. For a complete list of both covered and not-covered services, including benefits required by your state, see your employer's insurance certificate or summary plan description -- the official plan documents. If there are any differences between this summary and the plan documents, the information in the plan documents takes precedence. "CIGNA," the "Tree of Life" logo, "CIGNA Healthcare," "CIGNA Care Network," "CIGNA Behavioral Health," "CIGNA Choice Fund," "CIGNA Well Aware for Better Health" and "myCIGNA.com" are registered service marks, and "CIGNA Pharmacy," CIGNA Home Delivery Pharmacy," "CIGNA Well Informed" and "CIGNA Behavioral Advantage" are service marks, of CIGNA Intellectual Property, Inc., licensed for use by CIGNA Corporation and its operating subsidiaries. All products and services are provided exclusively by such operating subsidiaries and not by CIGNA Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company (CGLIC), CIGNA Health and Life Insurance Company (CHLIC), CIGNA Behavioral Health, Inc., Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C. and HMO or service company subsidiaries of CIGNA Health Corporation and CIGNA Dental Health, Inc. In Arizona, HMO plans are offered by CIGNA HealthCare of Arizona, Inc. In Connecticut, HMO plans are offered by CIGNA HealthCare of Connecticut, Inc. In North Carolina, HMO plans are offered by CIGNA HealthCare of North Carolina, Inc. In California, HMO and Network plans are offered by CIGNA HealthCare of California, Inc. All other medical plans in these states are insured or administered by CGLIC or CHLIC. “CIGNA Home Delivery Pharmacy” refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C.

Source: http://liuff.org/Buy%20Up%202%20PPO%20LIU%202012%20EE.pdf