MEDICAL BENEFITS SCHEDULE

MEDICAL BENEFITS SCHEDULE

NETWORK PROVIDERS NON-NETWORK PROVIDERS

MAXIMUM CALENDAR

YEAR BENEFIT AMOUNT

UNLIMITED

DEDUCTIBLE, PER

CALENDAR YEAR

Per Covered Person

Per Family Unit

$1,500

$4,500

$3,000

$9,000

Note: The Network and Non-Network Deductibles cross apply so that the combined maximum shall

not exceed 3,000 per person ($9,000 Family)

COPAYMENTS

Outpatient rehab therapy

(physical/occupational,

speech, pulmonary, cardiac

& post-cochlear implant

aural therapy)

Urgent Care center *

Emergency Room visits

(waived for admissions)

Physician office visits: *

family/general practice,

internal medicine, OB/GYN,

pediatrician, mental/nervous

and substance abuse provider

Specialist office visits *

$25

$75

$200

$25

$50

N/A

N/A

$200

N/A

N/A

* Includes all services performed in or billed by the Physician’s office (or urgent care center) except

for: CT, PET, MRI, nuclear medicine, scopic procedures, surgery, dialysis, intravenous chemotherapy,intravenous infusion therapy, and radiation

MAXIMUM OUT-OF-POCKET

AMOUNT, PER CALENDAR

YEAR (including deductibles)

$1,500

$4,500

$6,000

$12,000

Per Covered Person

Per Family Unit

Note: The Network and Non-Network out-of-pocket maximums cross apply so that the combined

maximum shall not exceed 6,000 per person ($12,000 Family)

The Plan will pay the designated percentage of covered charges until out-of-pocket amounts are

reached; at which time the Plan will pay 100% of the remainder of covered charges for the rest of the

Calendar Year unless stated otherwise.

The following charges do not apply toward the out-of-pocket maximum and are never paid at 100%:

Cost containment penalties and Copayments

COVERED SERVICES NETWORK PROVIDERS NON-NETWORK PROVIDERS

Hospital Services

Room and Board 100% after deductible

semiprivate or private room rate

80% after deductible


Intensive Care Unit 100% after deductible

Hospital's ICU Charge


Hospital's ICU Charge

Other services 100% after deductible 80% after deductible

Emergency Room visits

Medical Emergency 100% after copay 100% after copay

Medical Non-Emergency Care 100% after deductible 80% after deductible

Skilled Nursing Facility 100% after deductible




60 days Calendar Year maximum

Urgent Care Center 100% after copayment 80% after deductible

Physician Services

Inpatient visits 100% after deductible 80% after deductible

Surgery 100% after deductible 80% after deductible

Office visit 100% after copayment 80% after deductible

Home Health Care 100% after deductible 80% after deductible

60 visits Calendar Year maximum

Hospice Care 100% after deductible 80% after deductible

Ambulance Service 100% after deductible 100% after deductible

Outpatient pulmonary rehab 100% after copayment 80% after deductible


Outpatient cardiac rehab 100% after copayment 80% after deductible


Outpatient physical therapy 100% after copayment 80% after deductible


Outpatient occupational

therapy

100% after copayment 80% after deductible


Outpatient speech therapy 100% after copayment 80% after deductible


Outpatient post-cochlear 100% after copayment 80% after deductible

implant aural therapy 30 visits Calendar Year maximum

Spinal Manipulation/

Chiropractic

100% after copayment 80% after deductible

Durable Medical Equipment 100% after deductible 80% after deductible

Prosthetics 100% after deductible 80% after deductible

Mental Disorders and Substance Abuse Treatment

Inpatient

Outpatient office visit

Other Outpatient services


100% after copayment





Hearing Aids 100% after deductible 80% after deductible

(limited to Dependent children

under age 18)

Limited to one hearing aid per hearing

impaired ear every 36 months

Preventive Care

Routine Well Adult/Child

Care including:

Immunizations

Well baby care

Mammograms

Routine Physical exam

Routine GYN visit

Prostate/rectal exam

Hemoccult (colon) test

Colonoscopy/sigmoidoscopy

Vision

Breast Pump

100% after copay

one per Calendar Year, or more

frequent if recommended by Dr.

one per Calendar Year, including

related diagnostic tests performed

during same visit.

one visit and one pap smear per

Calendar Year (two if deemed

medically necessary)

one per Calendar Year (two if

deemed Medically Necessary)

one per Calendar Year

one exam every two Calendar

Years

up to a $150 maximum per

pregnancy in conjunction with

childbirth.

Not covered

Routine Well Newborn Care 100% after deductible 80% after deductible

Organ Transplants 100% after deductible 80% after deductible

Plan only covers donor cost

when recipient is covered

Pregnancy (dependent

pregnancy excluded)

Initial office visit

Other care and services

100% after copayment




PRESCRIPTION DRUG BENEFIT

Pharmacy Option - Copayment per Prescription

Generic………………………………………………………………………..… $ 10

Formulary (preferred brand)……………..……………………………………... $ 30

Non-formulary………………….………………………………………………. $ 60

Mail Order Option – Copayment per Prescription

Generic………………………………………………………………………….. $ 25

Formulary……………………………………………………………………….. $ 75 Non-formulary…………………………………………………………………... $150

COST MANAGEMENT SERVICES

Cost Management Services Phone Number

Please refer to the Employee ID card for the Cost Management Services phone number.

The provider, patient or family member must call this number to receive certification of certain Cost Management

Services. This call must be made at in advance of services being rendered or within 48 hours after a Medical

Emergency.

Any reduced reimbursement due to failure to follow cost management procedures will not accrue toward the

100% maximum out-of-pocket payment.

UTILIZATION REVIEW

Utilization review is a program designed to help ensure that all Covered Persons receive necessary and appropriate

health care while avoiding unnecessary expenses.

The program consists of:

(a) Precertification of the Medical Necessity for the following non-emergency services before

Medical and/or Surgical services are provided:

Hospitalizations

Outpatient procedures

Inpatient Medical Care Facility for Mental Disorder and Substance Abuse Treatment

Outpatient Medical Care Facility for Mental Disorder and Substance Abuse Treatment

(See attached Addendum for further details on pre-certification. Please note that the

categories listed on the Addendum are examples and does not guarantee that a procedure

listed is covered by the Plan)

(b) Retrospective review of the Medical Necessity of the listed services provided on an emergency

basis;

(c) Concurrent review, based on the admitting diagnosis, of the listed services requested by the

attending Physician; and

(d) Certification of services and planning for discharge from a Medical Care Facility or cessation of

medical treatment.

This program is not designed to be the practice of medicine or to be a substitute for the medical judgment of the

attending Physician or other health care provider.

Authorization given by the utilization review administrator for Preadmission Certification is only for the purpose of

reviewing whether the service or supply is necessary to the care and treatment of the Sickness. Authorization does not

guarantee that all charges are covered under the Plan. All charges submitted are subject to all other terms and

conditions of the Plan.

If a particular course of treatment or medical service is not certified, it means that either the Plan will not pay for the

charges or the Plan will not consider that course of treatment as appropriate for the maximum reimbursement under

the Plan. The patient is urged to find out why there is a discrepancy between what was requested and what was

certified before incurring charges.

The attending Physician does not have to obtain precertification from the Plan for prescribing a maternity length of stay that is 48 hours or less for a vaginal delivery or 96 hours or less for a cesarean delivery.

In order to maximize Plan reimbursements, please read the following provisions carefully.

Addendum

TPA Name Benefit Administration Services Group Name Dudley Debosier Cigna Group No. 1216

Medical Necessity Review

Chiropractic and PT / OT Precertification for Chiropractic and Physical Therapy/Occupational Therapy (PT/OT) is defined as Medical Necessity Review (MNR) after the initial 5 visits

and is only available for select geographies performed by participating providers in the American Specialty Health (ASH) network.

A “yes” or “no” selection MUST be made for each item in the Medical Necessity Review section

Yes No

Chiropractic Services (Medical Necessity Review after the initial 5 visits for Participating Vendor Providers for Chiropractic Services)

X

Physical Therapy and Occupational Therapy (Medical Necessity Review after the initial 5 visits for Participating Vendor Providers for Physical Therapy and Occupational Therapy Services)

X

Optional Precertification Buy-Up Categories • Musculoskeletal and Pain Management (MSK) Program: A Per Employee Per

Month (PEPM) fee is associated with this category.• Oncology Management Program: An episode of care charge for a 12-month period

is associated with this category per identified patient.Please refer to the Utilization Management At A Glance document.

A “yes” or “no” selection MUST be made for each category on this Snapshot."

Yes No

Musculoskeletal and Pain Management (MSK) Program • Includes procedures performed in either an inpatient or outpatient

place of service, depending on the procedure being performed;includes interventional pain management and major joint surgery.

• Examples: Services that treat pain and discomfort in muscles,bones, and joints, including epidural steroid injections, facetinjections, epidural adhesiolysis, spinal cord stimulators, painpumps, radiofrequency ablation (RFA). Also includes surgicalprocedures for shoulder, hips, and knees.

X

Oncology Management Program • Oncology precertification program to review an oncology drug

treatment regimen addressing the entire course of treatment for amember, as opposed to the drug-by-drug approval.

• Uses proprietary algorithm review of member’s entire oncologytreatment plan, inclusive of medical infused medications, oral cancermedications, and support drugs.

• Allows health care professionals to access the expert guidelines of44 types of cancer treatment regimens defined by the NationalComprehensive Cancer Network (NCCN) for compliance to theirpathways guidelines.

• Also includes precertification of Pharmacy oncology drugs shouldCigna Pharmacy Benefits Management be included in the plan.

Recommended for the management of high-cost specialty drugs

X

Addendum


Precertification Requirements

Inpatient Precertification The categories below are outlined in the Cigna UM At A Glance document

(Examples have been provided but are not inclusive of all services). All Inpatient categories are a required component of Cigna's UM program. Only Cigna can perform

Utilization Management.

Acute Care- (Services rendered in the hospital setting not included in any other inpatient pre-cert category) Routine and high risk maternity (routine only if inpatient stay exceeds federal requirements) Long term acute care Skilled Nursing Facility Rehabilitation Detox IP Mental Health and Substance Abuse hospital IP Mental Health and Substance Abuse residential

Outpatient Precertification The categories below are outlined in the

Outpatient Precertification Categories and the UM At A Glance documents. (Examples have been provided but are not inclusive of all services)

A “yes” or “no” selection MUST be made for each category on this Snapshot."

Yes No

Cochlear Implants • Osseointegrated, cochlear or auditory brain stem implant

X

Diagnostic radiology • CT scans, MRI/MRA, myocardial perfusion imaging, PET scans,

cardiac blood pool imaging and cardiac tests including diagnosticcardiac catheterizations and stress echocardiograms

X

Durable medical equipment • Seat lifts, TENS, pumps, wheelchairs, power operated vehicles,

speech generating devices, insulin infusion pump, osteogenesisstimulators, neuromuscular stimulators

X

Erectile dysfunction • Penile implants (does not include erectile dysfunction drugs)

X

Gastric bypass • Gastrectomy, gastric restrictive procedures, lap sleeve, revision of

stomach-bowel fusion

X

Addendum


Home Health Care (home nursing care) Recommended for the management of high-cost specialty drugs

• Registered nurse, licensed practical nurse or aid in the home

X

Home infusion therapy Recommended for the management of high-cost specialty drugs

• Home infusion therapy for immunotherapy, continuous medications,hydration, total parenteral nutrition, pain management

X

Injectable medications Recommended for the management of high-cost specialty drugs

• Immune globulin, drugs for factor deficiencies, interferon, Rituxan,some chemotherapeutic agents, botox

X

Oral pharynx procedures • Uvulectomy, LAUP procedures, palatopharyngoplasty (PPP),

uvulopalatopharyngoplasty (UPP)

X

Orthotics and prosthetics • Helmets, extremity prosthetic additions, electric prosthetic joints,

facial prosthesis provided by nonphysician, voice amplifiers, cranialremolding orthosis, lower extremity orthosis, knee brace

X

Outpatient procedures (not otherwise categorized) Does not include all outpatient surgeries

• Facial reconstruction, varicose vein treatment, breast reconstructionor reduction, blepharoplasty, rhinoplasty

X

Potential experimental/investigational/unproven procedures Recommended for the management of high-cost specialty drugs

• Keratoplasty, total disc arthroplasty, molecular pathology and geneanalysis, air ambulance, private duty nursing, arthrodesis, externaldefibrillator, biologic implant

X

Sleep Management Program • Obstructive sleep apnea, diagnostic or therapeutic sleep studies

X

Speech Therapy • Treatment and services of speech, language and voice. Can also be

performed in the home setting

X

Spinal procedures • Allograft/osteopromotive material for spine surgery, osteotomy,

percutaneous vertebroplasty, arthrodesis, laminectomy, vertebralcorpectomy, destruction by neurolytic agent, laminotomy, facet jointnerve destruction, spinal cord decompression

X

Therapeutic radiology • Brachytherapy, proton beam therapy, radiotherapy

X

Transplants Required opt in with Cigna Lifesource Transplant Network • Adult or pediatric, living or cadaveric donors for heart, heart/lung,

intestinal, liver, pancreas, pancreatic islet cell, multivisceral solidorgan transplants; preparation for and includingallogeneic/autologous hematopoietic/bone marrow transplants;transplant-related travel and lodging

X

Unlisted procedures • Vascular surgery, miscellaneous DME, unclassified drugs/biologics

including antineoplastics, lower extremity prosthesis

X

PLAN EXCLUSIONS

Note: All exclusions related to Prescription Drugs are shown in the Prescription Drug Plan.

For all Medical Benefits shown in the Schedule of Benefits, a charge for the following is not covered:

(1) Abortion. Services, supplies, care or treatment in connection with an abortion unless the life of the

mother is endangered by the continued Pregnancy.

(2) Acupressure. Expenses for acupressure will not be considered eligible.

(3) Acupuncture.

(4) Biofeedback.

(5) Complications of non-covered treatments. Care, services or treatment required as a result of

complications from a treatment not covered under the Plan are not covered. Complications from a non-

covered abortion are covered.

(6) Cosmetic surgery. Services and supplies related to cosmetic surgery. This exclusion does

not apply to reconstructive surgery charges shown as covered in the medical benefits

section of the Plan.

(7) Custodial care. Services or supplies provided mainly as a rest cure, maintenance or Custodial Care.

(8) Educational or vocational testing. Services for educational or vocational testing or training.

(9) Excess charges. The part of an expense for care and treatment of an Injury or Sickness that is in excess

of the Usual and Reasonable Charge.

(10) Exercise programs. Exercise programs for treatment of any condition, except for Physician-supervised

cardiac rehabilitation, occupational or physical therapy if covered by this Plan.

(11) Experimental or not Medically Necessary. Care and treatment that is either

Experimental/Investigational or not Medically Necessary.

(12) Eye care. Radial keratotomy or other eye surgery to correct refractive disorders. Also, routine eye

examinations, including refractions, lenses for the eyes and exams for their fitting. This exclusion does

not apply to aphakic patients and soft lenses or sclera shells intended for use as corneal bandages, the

Medically Necessary initial lens following cataract surgery (excluding multi-focal lenses), or as may be

covered under the well adult or well child sections of this Plan or vision services listed in the Schedule of

Benefits.

(13) Foot care. Treatment of weak, strained, flat, unstable or unbalanced feet, metatarsalgia or bunions

(except open cutting operations), and treatment of corns, calluses or toenails (unless the charges are for

the partial or complete removal of the nail roots, or needed in treatment of a metabolic or

peripheral-vascular disease).

(14) Foreign medical treatment. Care, treatment or supplies out of the U.S. if travel is for the sole purpose

of obtaining medical services.

(15) Government coverage. Care, treatment or supplies furnished by a program or agency funded by any

government. This exclusion does not apply to Medicaid or when otherwise prohibited by applicable law.

(16) Hair loss. Care and treatment for hair loss including wigs, hair transplants or any drug that promises hair

growth, whether or not prescribed by a Physician.

(17) Hearing aids and exams. Charges for services or supplies in connection with hearing aids or exams for

their fitting, except as listed in the Schedule of Benefits.

(18) Homeopathic Treatment. Expenses for naturopathic and homeopathic treatments, services and supplies

will not be considered eligible.

(19) Hospital employees. Professional services billed by a Physician or nurse who is an employee of a

Hospital or Skilled Nursing Facility and paid by the Hospital or facility for the service.

(20) Hypnosis. Services, supplies, care or treatment in connection with Hypnosis.

(21) Illegal acts. Charges for services received as a result of Injury or Sickness caused by or contributed to by

engaging in an illegal act or occupation; by committing or attempting to commit any crime, criminal act,

assault or other felonious behavior; or by participating in a riot or public disturbance. This exclusion

does not apply if the Injury resulted from an act of domestic violence or a medical (including both

physical and mental health) condition.

(22) Impotence. Care, treatment, services, supplies or medication in connection with treatment for

impotence.

(23) Infertility. Services and associated expenses for infertility treatments, including assisted reproductive

technology, regardless of the reason for treatment. Surrogate parenting, donor eggs, donor sperm and

host uterus. Storage and retrieval of all reproductive materials. Examples include eggs, sperm, testicular

tissue and ovarian tissue. This exclusion does not apply to services required to treat or correct underlying

causes of infertility.

(24) Intrauterine Device (IUD) Charges in connection with the purchase and insertion of an IUD.

(25) Marital or pre-marital counseling. Care and treatment for marital or pre-marital counseling.

(26) Massage therapy. Services, supplies, care or treatment in connection with a message therapist.

(27) Missed Appointments. Expenses for missed appointments will not be considered eligible.

(28) No charge. Care and treatment for which there would not have been a charge if no coverage had been in

force.

(29) Non-compliance. All charges in connection with treatments or medications where the patient either is in

non-compliance with or is discharged from a Hospital or Skilled Nursing Facility against medical advice.

(30) Non-emergency Hospital admissions. Care and treatment billed by a Hospital for non-Medical

Emergency admissions on a Friday or a Saturday. This does not apply if surgery is performed within 24

hours of admission.

(31) No obligation to pay. Charges incurred for which the Plan has no legal obligation to pay.

(32) No Physician recommendation. Care, treatment, services or supplies not recommended and approved

by a Physician; or treatment, services or supplies when the Covered Person is not under the regular care

of a Physician. Regular care means ongoing medical supervision or treatment which is appropriate care

for the Injury or Sickness.

(33) Not specified as covered. Non-traditional medical services, treatments and supplies which are not

specified as covered under this Plan.

(34) Obesity. Care and treatment of obesity, weight loss or dietary control whether or not it is, in any case, a

part of the treatment plan for another Sickness.

(35) Occupational. Care and treatment of an Injury or Sickness that is occupational -- that is, arises from

work for wage or profit including self-employment.

(36) Orthotics. Charges in connection with orthotics.

(37) Personal comfort items. Personal comfort items or other equipment, such as, but not limited to, air

conditioners, air-purification units, humidifiers, electric heating units, orthopedic mattresses, blood

pressure instruments, scales, elastic bandages or stockings, nonprescription drugs and medicines, and

first-aid supplies and nonhospital adjustable beds.

(38) Plan design excludes. Charges excluded by the Plan design as mentioned in this document.

(39) Private duty nursing. Charges in connection with care, treatment or services of a private duty nurse.

(40) Pregnancy of Dependent other than Spouse.

(41) Psychosurgery. Expenses for psychosurgery will not be considered eligible.

(42) Recreational and Educational Therapy. Expenses for recreational and educational services; learning

disabilities; behavior modification services; vocational testing or training; any form of non-medical self-

care or self-help training, including any related diagnostic testing; art therapy; music therapy;

aromatherapy; health club memberships; will not be considered eligible. Diabetic education is

considered eligible as specified under Eligible Medical Expenses. This exclusion will not apply to

expenses related to the diagnosis, testing and treatment of autism, ADD or ADHD.

(43) Relative giving services. Professional services performed by a person who ordinarily resides in the

Covered Person's home or is related to the Covered Person as a Spouse, parent, child, brother or sister,

whether the relationship is by blood or exists in law.

(44) Replacement braces. Replacement of braces of the leg, arm, back, neck, or artificial arms or legs, unless

there is sufficient change in the Covered Person's physical condition to make the original device no

longer functional.

(45) Routine care. Charges for routine or periodic examinations, screening examinations, evaluation

procedures, preventive medical care, or treatment or services not directly related to the diagnosis or

treatment of a specific Injury, Sickness or Pregnancy-related condition which is known or reasonably

suspected, unless such care is specifically covered in the Schedule of Benefits or required by applicable

law.

(46) Self-Inflicted. Any loss due to an intentionally self-inflicted Injury. This exclusion does not apply if the

Injury resulted from an act of domestic violence or a medical (including both physical and mental health)

condition.

(47) Services before or after coverage. Care, treatment or supplies for which a charge was incurred before a

person was covered under this Plan or after coverage ceased under this Plan.

(48) Sex changes. Care, services or treatment for non-congenital transsexualism, gender dysphoria or sexual

reassignment or change. This exclusion includes medications, implants, hormone therapy, surgery,

medical or psychiatric treatment.

(49) Sleep disorders. Care and treatment for sleep disorders unless deemed Medically Necessary.

(50) Smoking cessation. Care and treatment for smoking cessation programs, including smoking deterrent

products.

(51) Snoring Treatments. Expenses for snoring treatments, both medical and surgical will not be considered

eligible, except when provided as part of treatment for documented obstructive sleep apnea.

(52) Surgical sterilization reversal. Care and treatment for reversal of surgical sterilization.

(53) Sweating. Expenses relating to excessive sweating, both medical and surgical will not be considered

eligible.

(54) Temporomandibular Joint Syndrome. All diagnostic and treatment services related to the treatment of

jaw joint problems including temporomandibular joint (TMJ) syndrome.

(55) Travel or accommodations. Charges for travel or accommodations, whether or not recommended by a

Physician, except for charges shown as a Covered Charge.

(56) War. Any loss that is due to a declared or undeclared act of war.

(57) Wrong Surgeries. Additional costs/or care related to wrong surgeries. Wrong surgeries include, but are

not limited to, surgery performed on the wrong body part, surgery performed on the wrong person,

objects left in patients after surgery, etc.

Documents

MEDICAL BENEFITS SCHEDULE