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Member Summary For: |
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JOHN DOE |
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Relationship: EMPLOYEE |
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Date of Birth: 01/01/1970 |
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Product: CIGNA Choice Fund |
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Pharmacy Product: Tier 3 |
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Account Number: 1234567 |
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Effective Date: 01/01/2002 |
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Eligibility Status: Active |
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Physician: SMITH DAVID MD |
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Resources |
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| Please review your plan documents for full details, including exclusions, limitations and state mandates that might affect the benefits described below. |
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| Deductibles |
In-Network |
Out-of-Network |
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| Individual |
$2,000.00 |
$2,500.00 |
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| Family |
$4,000.00 |
$5,000.00 |
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Member's Coinsurance Percents |
In-Network |
Out-of-Network |
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| Office Visit |
20% |
40% |
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| Specialist Office Visit |
20% |
40% |
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| Inpatient Hospital |
20% |
40% |
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| Outpatient Hospital |
20% |
40% |
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| Emergency/Urgent
Care |
20% |
20% |
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| Ambulance |
20% |
40% |
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| Chiropractic Care |
20% |
40% |
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| Diagnostic Lab and
X-Ray |
20% |
40% |
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| Durable Medical Equipment |
20% |
40% |
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| External
Prosthetic Appliances |
20% |
40% |
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| Family
Planning |
20% |
40% |
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| Home
Health Care |
20% |
40% |
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| Maternity
Services |
20% |
40% |
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| Organ
Transplant |
20% |
20% |
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| Short
Term Rehabilitation |
20% |
40% |
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| Skilled
Nursing Facility |
20% |
40% |
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| Treatment
for Tempo Mandibular Joint |
20% |
40% |
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Out-of-Pocket Maximums |
In-Network |
Out-of-Network |
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| Individual |
$5,000.00 |
$6,000.00 |
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| Family |
$10,000.00 |
$12,000.00 |
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Benefit Maximums |
In-Network |
Out-of-Network |
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| Chiropractic
Care (Visits) |
20 Per Calendar Year |
20 Per Calendar Year |
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| Short
Term Rehabilitation (Visits) |
20 Per Calendar Year |
20 Per Calendar Year |
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Treatment
for Tempo Mandibular Joint
(Dollar Amount) |
$600 Per Lifetime |
$600 Per Lifetime |
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| Lifetime
Maximum |
$1,000,000.00 |
$1,000,000.00 |
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Authorizations |
In-Network |
Out-of-Network |
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| Inpatient
Pre-Admittance Certification/Continued Stay Review |
Yes |
Yes |
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| Emergency
Services Notification Hours |
24 Hours |
24 Hours |
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Pharmacy Services |
Generic |
Preferred Brand |
Non-Preferred Brand |
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Pharmacy Copayments |
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| Retail Copay (30 Day Supply) |
$10.00 |
$30.00 |
$50.00 |
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| Mail Order Copay (90 Day Supply) |
$20.00 |
$60.00 |
$100.00 |
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