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Microsoft word - bsf79543.doc
Your Preferred In-Network
Provider Access Plan CHOICE OF DOCTORS
You can use any “preferred provider” in
You’re still covered when you go out of
our network without a referral. Or, when
network, though your cost will be higher.
you wish, you can go out of network.
When you receive care from a preferred
deductible. See the out-of-network costs
low-cost coverage in
providers in your “CIGNA HealthCare
DEDUCTIBLES AND OUT-OF-
Your plan deductibles do not apply to the
In the private office of your physician.
pays 100% of eligible charges for the rest
of the plan year, except for Mental Health
of network when
hospital in our network and your stay has and Substance Abuse which continue to
CIGNA'S TOLL-FREE CARE LINE
Call for steps to take before admittance to
THESE ARE ONLY THE
a hospital, or for assistance in finding a
If you have any questions about a specific
or out of town. Call CIGNA customer
service or treatment, contact Customer
service at the toll-free number indicated
on your ID Card for further information.
No matter where you travel in the U.S. or
worldwide, you’re covered for emergency
PPA – Copay Plan
care. See your “CIGNA HealthCare
NO CLAIMS OR
For Employees of
LEGAL SERVICES FOR
NEW YORK CITY
AT A GLANCE
Annual Out-of-Pocket Maximum
Pre-existing Condition Limitation
Continued Stay Review
Call the toll free number indicated on ID Card.
Call the toll free number indicated on ID Card.
Routine Preventive Care for Dependent Children
including Immunizations birth thru age 18
Routine Preventive Care
for Adults (
Well Adult Exams (including pap test, PSA, etc.)
$20 per visit, or actual charge whichever is less
NOTE: New York residents only: No charge
$20 per office visit copay for associated well
woman exam; No charge for separate outpatient facility
(includes oral contraceptives, diabetic drugs & supplies, prenatal prescription vitamins)
Generic - 30-day supply
Tel-Drug Mail Order Plan
$20 for first visit to confirm pregnancy, then
includes subsequent prenatal/postnatal visits
Office Visit incl. tests & counseling
Office Visit (includes tests & counseling)
(excludes in-vitro fertilization, artificial
Care will be covered at in-network benefit level if it
Hospital Emergency Room/Urgent Care Facility
meets CIGNA HealthCare's definition of emergency
Outpatient Preadmission Testing
Office Visit- Primary Care Physician/Specialist
Inpatient Hospital Care
Facility charges (Limited to semi-private room rate)
Outpatient Surgical Facility
Outpatient Short-Term Rehabilitation
incl. Physical, Speech & Occupational Therapy Chiropractic Therapy
Second Surgical Opinion
X-ray and Lab
Mental Health Services
Substance Abuse Treatment
* Subject to calendar year deductible and reasonable and customary charge limitations for out-of-network services. ** Treatment maximums cross-accumulate.
All deductibles and plan out-of-pocket maximums accumulate in one direction toward in-network unless otherwise noted.
Regarding In-Network and Out-of-Network services:
Once the out-of-pocket maximum is reached, the plan pays 100% of eligible charges for the remainder of the plan year, except for Mental Health and Substance Abuse which continue to be paid at the levels specified.
All inpatient hospital admissions require Preadmission Certification and Continued Stay Review. To pre-certify, call the toll free number indicated on your ID card.
Regarding In-Network services:
All services must be provided by one of the preferred providers on our list. Regarding Out-of-Network services:
Your out-of-pocket costs will be higher than with a preferred provider.
Mental Health and Substance Abuse Services
are provided by CIGNA Behavioral Health,
such expenses are incurred for: a) charges
access care, call 24 hours a day, 7 days a week
treatment started within six months of an
at the toll free number listed on your ID Card.
Custodial services not intended primarily
injury to sound, natural teeth; b) charges
to treat a specific injury or sickness, or
Coordinated by CIGNA HealthCare. This is a
service designed to provide assistance to a
hospitalizations not required for health
patient who is at risk of developing medical
complexities or for whom a health incident
has precipitated a need for rehabilitation or
additional health care support. The program
Charges for or in connection with in vitro
strives to attain a balance between quality and
fertilization, artificial insemination, or
This summary contains highlights only and is
cost effective care while maximizing the
subject to change. The specific terms of
Transsexual surgery and related services.
coverage, exclusions, and limitations,
including legislated benefits, are contained in
the Plan Description or insurance certificate.
Your plan provides coverage for medically
This Plan is insured and/or administrated by
Connecticut General Life Insurance Company,
provide coverage for the following except as
Services that are not medically necessary,
determination of a fetus, unless medically
necessary to determine the existence of a
receives an injury which results in bodily
pills, minoxidil or Retin-A after age 35,
necessary; c) it qualifies as reconstructive
the other breast to achieve symmetry; or
d) it is performed to correct a congenital
developed; b) can be considered custodial
or educational; or c) intended to maintain
which is not restorative in nature, will not
charges are directly related to a sickness
or injury connected to military service.
lenses with the exception of the first pair
Catalog Number: BSF79543 (09/04)
“CIGNA HealthCare” refers to various operating subsidiaries of CIGNA Corporation. Products and services are provided by these subsidiaries and not by CIGNA Corporation. These subsidiaries include Connecticut General Life Insurance Company., Tel-Drug, Inc. and its affiliates, CIGNA Behavioral Health, Inc., Intracorp, and HMO or service company subsidiaries of CIGNA Health Corporation and CIGNA Dental Health, Inc.
HOW TO TREAT VOMITING & DIARRHEA IN DOGS Home treatment of vomiting and diarrhea Specific treatments of vomiting are dependent on the cause. Here is the general approach to treating vomiting and diarrhea: If your pet vomits once and/or has a small amount of diarrhea then eats normally with no further vomiting, has a normal bowel movement and is acting playful, then the problem ma
La prassi del restauro dei manufatti in stucco. Un’analisi delle procedure d’intervento. Tavole riassuntive. Le relazioni tecniche. ASPETTI considerati nello scritto 1 - Consolidamento e stuccatura dei manufatti 2- Pulitura dei manufatti *Specializzanda in Restauro dei Monumenti presso la Facoltà di“Gli interventi di restauro sulla decorazione della 1984Bollettin