HRA EE Summary FINAL 2011 2012 by DtxA2waZ

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									SUMMARY OF BENEFITS
Your Maricopa Integrated Health System and CIGNA Choice FundSM
Health Reimbursement Arrangement-Open Access Plus plan
Features that Add Value                            Quality Service Is Part of                                improve your health. Only you, your doctor
                                                                                                             and CIGNA have access to this information.
   CIGNA Choice Fund combines                     Quality Care                                             CIGNA Well Aware for Better Health® can
    conventional health coverage with health            Service is at the heart of everything we do.
    funds to help you pay for the cost of your                                                               help you manage certain chronic conditions.
                                                         Our goal is to give you fast, accurate             The CIGNA HealthCare Healthy Babies
    covered health care services. See next page          answers; responsive, courteous and
    for more information.                                                                                    program provides you with information to
                                                         professional assistance; and ease and               help you have a healthy pregnancy and a
   Your plan offers the convenience of                  convenience in finding the information you          healthy baby.
    referral-free access to doctors, and the             need to manage your health.
    option to select a personal Primary Care            www.cigna.com – Visit our interactive Web       You Can Depend on CIGNA
    Physician (PCP) as your source for routine           site to learn more about your plan and get
    care and guidance when you need specialized          health information, 24 hours a day. Once        HealthCare
    care. As your needs change, so may your              you enroll, register for myCIGNA.com, our          Quality comes first. We select participating
    choice of doctors. That’s why you can                convenient, secure web site that combines           providers carefully. And we make sure you
    change your PCP for any reason.                      WebMD® tools with personalized benefits             have a wide range of doctors to choose from.
   The CIGNA HealthCare 24-Hour Health                  information to help you make the most of           Emergency and urgent care are covered
    Information LineSM connects you to trained           your plan.                                          wherever you go, worldwide, 24 hours a
    nurses and a library of hundreds of recorded        We Speak Many LanguagesSM . We offer                day. Urgent care centers can take care of
    programs on important health topics 24 hours         the Language Line Services so that you can          your urgent care needs, and your cost is
    a day, seven days a week, from anywhere in           talk with us in 140 different languages. Just       lower.
    the U.S.                                             call Customer Service, and ask for an
   CIGNA Healthy Rewards includes special              interpreter to assist you.
                                                                                                         It’s Your Choice
    offers on health and wellness programs and
    services often not covered by many             It’s Your Health                                      When you visit network providers, you get access
                                                                                                         to quality care at the lowest out-of-pocket costs.
    traditional benefits plans. Just call          When you choose CIGNA HealthCare, you can             Your plan also offers the freedom to choose the
    1.800.870.3470 or visit our web site at        take advantage of our health and wellness             providers you prefer — even if they aren’t part of
    www.cigna.com.                                 programs:                                             the network. Your benefits are the highest when
   Prescription drug coverage is a part of your       Preventive care services for your children       you see “preferred providers,” but you're still
    plan. With national and independent                 through age 2 and any additional preventive      covered for visits to other providers. Participating
    pharmacies participating across the country,        care benefits described in the Benefits          providers charge a discounted rate for CIGNA
    you can have your prescription filled
                                                        Highlights.                                      members. If you use a non-network provider, the
    wherever you go. CIGNA Home Delivery
                                                       CIGNA Well Informed provides members             provider may bill you for the difference between
    Pharmacy gives you quick, convenient
                                                        with customized medical and wellness             the billed charge and the allowed amount under
    delivery of your medications right to your
                                                        information to help them make healthier          your benefit plan, in addition to applicable (higher
    home.                                               choices, better understand a diagnosis or        than in-network) deductibles and coinsurance
                                                        treatment, and manage their health. The          amounts.
                                                        program includes personalized letters and
                                                        other educational information to help you
                                                                                                                 Effective July 1, 2011

                                                                                                                                            Page 1
                                                       Client Specific Network –Maricopa Integrated Health System & CCF HRA Open Access Plus - 2011
                                Patient Protection and Affordable Care Act Required Notices




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.

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.




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                                              Client Specific Network –Maricopa Integrated Health System & CCF HRA Open Access Plus - 2011
                                               HOW YOUR CIGNA CHOICE FUND WORKS

                                                             Employer Contribution
    1.   Your employer establishes a health fund that can be used to pay for any covered health care expenses during that year. Amounts paid by
         the fund for services covered by the health plan are applied toward the plan deductible. This amount is pro-rated based on your effective
         date. Your deductible is not pro-rated.

                                                                 Your Contribution
    2.   Once you have used the dollars in your health fund, you pay your expenses up to the remaining plan deductible.

                                                              Your Employer and You
    3.   Once your deductible is met, your medical plan begins providing coverage for eligible services, as described below. Your deductible is not
         pro-rated during the year.



HEALTH REIMBURSEMENT ARRANGEMENT

                                                  Employee                          Employee + One                             Family

Employer Contribution                                $750                                 $1,500                               $1,500




                                                                                                                                         Page 3
                                                    Client Specific Network –Maricopa Integrated Health System & CCF HRA Open Access Plus - 2011
                                                                       Tier 1                                               Tier 2                                            Tier 3
                                                             Maricopa Integrated Health                              CIGNA Open Access                                 CIGNA Open Access
KEY BENEFIT INFORMATION
                                                                   System (MIHS)                                       Plus In-Network                                 Plus Out-Of-Network
                                                                     YOU PAY                                              YOU PAY                                           YOU PAY
Lifetime Maximum                                             Unlimited                                        Unlimited                                         Unlimited
Contract Year Combined Medical and Pharmacy
Deductible
Individual                                                   $2,000                                           $2,000                                            $6,000
Family                                                       $4,000                                           $4,000                                            $12,000
Contract Year Combined Medical and Pharmacy Out-             Includes Plan Deductible                         Includes Plan Deductible                          Includes Plan Deductible
of-Pocket Maximum
Individual                                                   $2,000                                           $2,000                                            $6,000
Family                                                       $4,000                                           $4,000                                            $12,000
Coinsurance                                                  Maricopa Integrated Health System pays           CIGNA HealthCare pays 100% of eligible            CIGNA HealthCare pays 70% of eligible
                                                             100% of eligible charges. You pay 0% of          charges. You pay 0% of charges after plan         charges. You pay 30% of charges after
                                                             charges.                                         deductible.                                       plan deductible.
Precertification -Inpatient – (required for all inpatient    Coordinated by your physician                    Coordinated by your physician                     Participant must obtain approval for
admissions)                                                                                                                                                     inpatient admission ; subject to
                                                                                                                                                                penalty/reduction or denial for non-
                                                                                                                                                                compliance

Pre-existing Condition Limitation (PCL)                      Yes                                              Yes                                               Yes

                                                            Not applicable to anyone under 19 years old.    Not applicable to anyone under 19 years old.       Not applicable to anyone under 19 years old.

                                                            Applies to anyone injury or sickness that you Applies to anyone injury or sickness that you are Applies to anyone injury or sickness that you are
                                                            are diagnosed with and receive treatment for, diagnosed with and receive treatment for, or         diagnosed with and receive treatment for, or
                                                            or incur expenses for during the 90 days before incur expenses for during the 90 days before you incur expenses for during the 90 days before you
                                                            you are insured by these benefits or you begin are insured by these benefits or you begin an       are insured by these benefits or you begin an
                                                            an eligibility waiting period (whichever is     eligibility waiting period (whichever is earlier). eligibility waiting period (whichever is earlier).
                                                            earlier).                                       Please refer to your plan documents for specific Please refer to your plan documents for specific
                                                            Please refer to your plan documents for         details.                                           details.
                                                            specific details.




                                                                                                                                                                Page 4
                                                                           Client Specific Network –Maricopa Integrated Health System & CCF HRA Open Access Plus - 2011
                                                                    Tier 1                                   Tier 2                              Tier 3
                                                          Maricopa Integrated Health                  CIGNA Open Access                   CIGNA Open Access
BENEFIT HIGHLIGHTS
                                                                System (MIHS)                           Plus In-Network                   Plus Out-Of-Network
                                                                  YOU PAY                                  YOU PAY                             YOU PAY
Primary Care Physician's (PCP)Office visit               No charge after plan deductible*       No charge after plan deductible*     30% of charges**

Specialty Care Physician's Office Visit                   No charge after plan deductible*      No charge after plan deductible*     30% of charges**
Consultant and Referral Physician's Services
 Note: A copayment applies for OB/GYN visits. If your
 doctor is listed as a PCP in the provider directory, you
 will pay a PCP copayment. If your doctor is listed as a
 specialist, you will pay the specialist copayment.

Allergy Treatment/Injections – PCP or Specialty          No charge after plan deductible*       No charge after plan deductible*     30% of charges**
Physician


Allergy Serum (dispensed by physician in office)         No charge after plan deductible*       No charge after plan deductible*     30% of charges**

Second Opinion Consultations (provided on voluntary      No charge after plan deductible*       No charge after plan deductible*     30% of charges**
basis)

Surgery Performed in the Physician’s Office- PCP or      No charge after plan deductible*       No charge after plan deductible*     30% of charges**
Specialty Physician

Acupuncture                                              No charge after plan deductible*       No charge after plan deductible*     Covered in-network only
Preventive Care
Routine Preventive Care-Well Baby Care, Well Child       No charge, no plan deductible          No charge, no plan deductible        Covered in-network only
Care and Adult Preventive Care
Unlimited maximum per contract year

Immunizations                                            No charge, no plan deductible          No charge, no plan deductible        Covered in-network only




                                                                                                                                                           Page 5
                                                                      Client Specific Network –Maricopa Integrated Health System & CCF HRA Open Access Plus - 2011
                                                                      Tier 1                                        Tier 2                                        Tier 3
                                                            Maricopa Integrated Health                       CIGNA Open Access                             CIGNA Open Access
BENEFIT HIGHLIGHTS
                                                                  System (MIHS)                                Plus In-Network                             Plus Out-Of-Network
                                                                    YOU PAY                                       YOU PAY                                       YOU PAY
Preventive Mammograms, PSA, Pap Test                       No charge, no plan deductible               No charge, no plan deductible                  Covered in-network only


                                                                                                                                                      30% of charges**
Diagnostic Mammograms, PSA, Pap Test                        No charge after plan deductible*           No charge after plan deductible*
Note: Diagnostic related services are paid at the same
level of benefits as other x-ray and lab services, based on                                                                                           30% of charges**
place of service.                                           No charge, no plan deductible, per visit   No charge, no plan deductible, per visit for
                                                            for associated wellness exam               associated wellness exam

Colonoscopies (Preventive and Diagnostic)                  No charge, no plan deductible               No charge, no plan deductible                  Covered in-network only
Inpatient Hospital Services including:                     No charge, no plan deductible               No charge after plan deductible*               30% of charges*
 Semi-Private Room and Board
 Diagnostic/Therapeutic Lab and X-ray                                                                                                                 Precertification required
 Drugs and Medication
 Operating and Recovery Room
 Radiation Therapy and Chemotherapy
 Anesthesia and Inhalation Therapy
 MRIs, MRAs, CAT Scans, PET Scans, etc.

Inpatient Hospital Doctor’s Visits/Consultations           No charge after plan deductible*            No charge after plan deductible*               30% of charges**
Inpatient Hospital Professional Services                   No charge after plan deductible*            No charge after plan deductible*               30% of charges**




                                                                                                                                                             Page 6
                                                                        Client Specific Network –Maricopa Integrated Health System & CCF HRA Open Access Plus - 2011
                                                                  Tier 1                                   Tier 2                               Tier 3
                                                        Maricopa Integrated Health                  CIGNA Open Access                    CIGNA Open Access
BENEFIT HIGHLIGHTS
                                                              System (MIHS)                           Plus In-Network                    Plus Out-Of-Network
                                                                YOU PAY                                  YOU PAY                              YOU PAY
Outpatient Facility Services includes:              No charge, no plan deductible            No charge after plan deductible*      30% of charges**
 Operating Room, Recovery Room, Procedure Room
 and Treatment Room and Observation Room including:
   Diagnostic/Therapeutic Lab and X-rays
   Anesthesia and Inhalation Therapy
                                                     No charge after plan deductible*
Physician & Outpatient Professional Services                                                 No charge after plan deductible*      30% of charges**

Laboratory and Radiology Services
(includes preadmission testing)
Physician’s Office                                      No charge, no plan deductible        No charge, no plan deductible         30% of charges**

Outpatient Hospital Facility                            No charge, no plan deductible        No charge, no plan deductible         30% of charges**


Emergency Room/Urgent Care Facility (billed by facility No charge, no plan deductible        No charge, no plan deductible         No charge; except if not a true emergency,
  as part of the Emergency Room/Urgent Care visit)                                                                                 then 30% of charges**

Independent X-Ray and/or Lab Facility                   No charge, no plan deductible        No charge, no plan deductible

Independent X-Ray and/or Lab Facility (in conjunction   No charge, no plan deductible        No charge, no plan deductible *       30% of charges**
  with an Emergency Room visit)
                                                                                                                                   30% of charges**
Advanced Radiological Imaging
(MRIs, MRAs, CAT Scans, PET Scans, etc.)

Outpatient Facility                                     No charge, no plan deductible        No charge after plan deductible*      30% of charges**

Emergency Room (billed by facility as part of the       No charge, no plan deductible        No charge after plan deductible*      No charge after plan deductible*; except if
Emergency Room visit)                                                                                                              not a true emergency, then 30% of
                                                                                                                                   charges**

Physician’s Office                                      No charge, no plan deductible         No charge after plan deductible*     30% of charges**




                                                                                                                                                         Page 7
                                                                    Client Specific Network –Maricopa Integrated Health System & CCF HRA Open Access Plus - 2011
                                                                   Tier 1                                      Tier 2                                   Tier 3
                                                         Maricopa Integrated Health                     CIGNA Open Access                        CIGNA Open Access
BENEFIT HIGHLIGHTS
                                                               System (MIHS)                              Plus In-Network                        Plus Out-Of-Network
                                                                 YOU PAY                                     YOU PAY                                  YOU PAY
Short-Term Rehabilitative Therapy --(includes cardiac
rehab, physical, speech, occupational, pulmonary
rehab & cognitive therapy)

Speech, Occupational and Physical Therapy                No charge; no plan deductible            No charge after plan deductible*          30% of charges**
                                                         60 days maximum per contract year# for   60 days maximum per contract year# for   20 days maximum per contract year# for all
                                                         each therapy                             all therapies combined                   therapies combined; reduced by in-network
                                                                                                                                           days

Cardiac rehab, pulmonary rehab and cognitive rehab       No charge after plan deductible*         No charge after plan deductible*          30% of charges**
                                                         60 days maximum per contract year# for   60 days maximum per contract year# for   20 days maximum per contract year# for all
                                                         all therapies combined                   all therapies combined                   therapies combined; reduced by in-network
Note: therapy sessions provided as part of Home Health                                                                                     days
Care accumulate to the Short-Term Rehab Therapy
maximum.

Chiropractic Services
Office Visit                                             No charge after plan deductible          No charge after plan deductible          30% of charges**
                                                         20 days maximum per contract year#       20 days maximum per contract year#       20 days maximum per contract year#
Emergency and Urgent Care Services
Physician’s Office – PCP or Specialty Physician          No charge after plan deductible*         No charge after plan deductible*         30% of charges**

Hospital Emergency Room                                  No charge after plan deductible*         No charge after plan deductible*         30% of charges**

Outpatient Professional Services (Radiology, Pathology   No charge after plan deductible*         No charge after plan deductible*         30% of charges**
and Emergency Room Physician)

Urgent Care Facility or Outpatient Facility              No charge after plan deductible*         No charge after plan deductible*         30% of charges**

Ambulance                                                No charge after plan deductible*         No charge after plan deductible*         30% of charges**




                                                                                                                                                          Page 8
                                                                     Client Specific Network –Maricopa Integrated Health System & CCF HRA Open Access Plus - 2011
                                                                  Tier 1                                   Tier 2                              Tier 3
                                                        Maricopa Integrated Health                  CIGNA Open Access                   CIGNA Open Access
BENEFIT HIGHLIGHTS
                                                              System (MIHS)                           Plus In-Network                   Plus Out-Of-Network
                                                                YOU PAY                                  YOU PAY                             YOU PAY
Maternity Care Services
Initial Office Visit to Confirm Pregnancy               No charge after plan deductible*      No charge after plan deductible*     30% of charges**

                                                                                              No charge after plan deductible*
All subsequent Prenatal Visits, Postnatal Visits and    No charge after plan deductible*                                           30% of charges**
Physician's Delivery Charges (total maternity fee)

Office Visits not included in the total maternity fee   No charge after plan deductible*      No charge after plan deductible*     30% of charges**
performed by OB or Specialty Physician


Delivery - Facility (Inpatient Hospital/Birthing Center  No charge, no plan deductible        No charge after plan deductible*     30% of charges*
Charges)                                                                                                                           precertification required
Inpatient Services at Other Health Care Facilities       No charge after plan deductible*    No charge after plan deductible*      30% of charges**
Skilled Nursing, Rehabilitation Hospital and Sub-Acute 60 days maximum per contract year#    60 days maximum per contract year#    60 days maximum per contract year#
Facilities                                              combined for all facilities listed   combined for all facilities listed    combined for all facilities listed

Home Health Care - Includes outpatient private duty     No charge after plan deductible*     No charge after plan deductible*      30% of charges**
nursing when approved as medically necessary            60 days maximum per contract year#   60 days maximum per contract year#    40 days maximum per contract year#;
                                                        16 hour maximum per day              16 hour maximum per day               reduced by any in-network days
                                                                                                                                   16 hour maximum per day
Hospice
Inpatient Services                                      No charge after plan deductible*      No charge after plan deductible*     30% of charges*

Outpatient Services                                     No charge after plan deductible*     No charge after plan deductible*      30% of charges**




                                                                                                                                                         Page 9
                                                                    Client Specific Network –Maricopa Integrated Health System & CCF HRA Open Access Plus - 2011
                                                                    Tier 1                                     Tier 2                              Tier 3
                                                          Maricopa Integrated Health                    CIGNA Open Access                   CIGNA Open Access
BENEFIT HIGHLIGHTS
                                                                System (MIHS)                             Plus In-Network                   Plus Out-Of-Network
                                                                  YOU PAY                                    YOU PAY                             YOU PAY
Family Planning Services
Office Visits (tests, counseling)                         No charge after plan deductible*        No charge after plan deductible*     30% of charges**


Note: The standard benefit will include coverage for
contraceptive devices (e.g. Depo-Provera, Norplant and
Intrauterine Devices (IUDs). Diaphragms will also be
covered when services are provided in the physician's
office.

Vasectomy/Tubal Ligation (excludes reversals)
Inpatient Facility                                        No charge, no plan deductible          No charge after plan deductible*      30% of charges*
                                                                                                                                       precertification required


Outpatient Facility                                       No charge, no plan deductible          No charge after plan deductible*      30% of charges**


Physician’s Services – Inpatient or Outpatient            No charge after plan deductible*       No charge after plan deductible*      30% of charges**

Physician’s Office                                        No charge after plan deductible*       No charge after plan deductible*      30% of charges**

Infertility Services

Office Visit (lab & radiology tests, counseling)-PCP or   No charge after plan deductible*       No charge after plan deductible*      Covered in-network only
Specialty Physician

Treatment/Surgery (includes artificial insemination, in-
vitro fertilization, GIFT, ZIFT, etc.)
Inpatient Facility                                       No charge, no plan deductible           No charge after plan deductible*      Covered in-network only

Outpatient Facility                                       No charge, no plan deductible          No charge after plan deductible*      Covered in-network only

Physician’s Services - Inpatient or Outpatient            No charge after plan deductible*        No charge after plan deductible*     Covered in-network only


TMJ - Surgical and Non-Surgical                           Not covered                             Not covered                          Not covered




                                                                                                                                                            Page 10
                                                                        Client Specific Network –Maricopa Integrated Health System & CCF HRA Open Access Plus - 2011
                                                                 Tier 1                                   Tier 2                                 Tier 3
                                                       Maricopa Integrated Health                  CIGNA Open Access                      CIGNA Open Access
BENEFIT HIGHLIGHTS
                                                             System (MIHS)                           Plus In-Network                      Plus Out-Of-Network
                                                               YOU PAY                                  YOU PAY                                YOU PAY
 Durable Medical Equipment                             No charge after plan deductible*       No charge after plan deductible*       30% of charges**
                                                       Unlimited maximum per contract year    Unlimited maximum per contract year    Unlimited maximum per contract year

 External Prosthetic Appliances                        No charge after plan deductible*       No charge after plan deductible*       30% of charges**

  Prescription Drugs Retail Drug Program               MIHS Pharmacies                        CIGNA Pharmacy Retail Drug Program     CIGNA Pharmacy Retail Drug Program
  Generic*** drugs on the Prescription Drug List for   No charge after plan deductible* per   No charge after plan deductible* per   Covered in-network only
  a 30-day supply                                      prescription/refill                    prescription/refill


  Brand Name*** drugs designated as preferred on       No charge after plan deductible* per   No charge after plan deductible* per   Covered in-network only
  the Prescription Drug List with no Generic           prescription/refill                    prescription/refill
  equivalent for a 30-day supply

                                                                                                                                     Covered in-network only
  Brand Name*** drugs with a Generic equivalent and No charge after plan deductible* per      No charge after plan deductible* per
  drugs designated as non-preferred on the          prescription/refill                       prescription/refill
  Prescription Drug List for a 30-day supply


  Prescription Drugs – Mail Order/90 day supply        MIHS Pharmacies                        CIGNA Home Delivery Pharmacy           CIGNA Home Delivery Pharmacy
                                                                                              Program - Mail Order                   Program – Mail Order
                                                       No charge after plan deductible* per
  Generic*** drugs on the Prescription Drug List for   prescription/refill                    No charge after plan deductible* per   Covered in-network only
  a 90-day supply                                                                             prescription/refill

                                                       No charge after plan deductible* per
  Brand Name*** drugs designated as preferred on       prescription/refill                    No charge after plan deductible* per   Covered in-network only
  the Prescription Drug List with no Generic                                                  prescription/refill
  equivalent for a 90-day supply

                                                    No charge after plan deductible* per
  Brand Name*** drugs with a Generic equivalent and prescription/refill                       No charge after plan deductible* per   Covered in-network only
  drugs designated as non-preferred on the                                                    prescription/refill
  Prescription Drug List for a 90-day supply


  ***Designated as per generally-accepted industry
  sources and adopted by CG




                                                                                                                                                       Page 11
                                                                   Client Specific Network –Maricopa Integrated Health System & CCF HRA Open Access Plus - 2011
                                                                  Tier 1                                        Tier 2                                      Tier 3
                                                        Maricopa Integrated Health                       CIGNA Open Access                           CIGNA Open Access
BENEFIT HIGHLIGHTS
                                                              System (MIHS)                                Plus In-Network                           Plus Out-Of-Network
                                                                YOU PAY                                       YOU PAY                                     YOU PAY
Mental Health and Substance Abuse Services

Mental Health
Inpatient –                                             No charge, no plan deductible              No charge after plan deductible*            30% of charges*
Unlimited maximum per contract year

Outpatient Mental Health (includes Individual, Group
Therapy and Intensive Outpatient services) –
Unlimited maximum per contract year

Physician’s Office                                      No charge after plan deductible*           No charge after plan deductible*            30% of charges**

Outpatient Facility                                     No charge after plan deductible*           No charge after plan deductible*            30% of charges**
Substance Abuse
Inpatient – Unlimited maximum per contract year         No charge, no plan deductible              No charge after plan deductible*            30% of charges*

Outpatient Substance Abuse (includes Individual and
Intensive Outpatient services) –
Unlimited maximum per contract year

Physician’s Office                                      No charge after plan deductible*           No charge after plan deductible*            30% of charges**

Outpatient Facility                                     No charge after plan deductible*           No charge after plan deductible*            30% of charges**
      * Services are subject to contract year deductible
      ** Out-of-network services are subject to contract year deductible and maximum reimbursable charge limitations. Providers may bill the member the
         difference between their billed charge and the maximum reimbursable charge as determined by the benefit plan.
      # In-network and out-of-network services apply to the same treatment or dollar maximum.

      Footnotes:
      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, including Mental
          Health and Substance Abuse services.
      Regarding In-Network Services:
         All services must be provided by one of the participating providers on our list in order to be covered.
      Regarding Out-of-Network Services:
         Your out-of-pocket costs will be higher than with a participating provider.
       All inpatient hospital admissions require Preadmission Certification and Continued Stay Review. Failure to obtain Preadmission Certification and/or Continued Stay Review
          may result in non-compliance penalties and/or reduction of benefits. Call the toll-free number on your CIGNA HealthCare ID Card.
         Coverage for pre-existing conditions will not be covered under this plan unless continuously insured for one year.



                                                                                                                                                        Page 12
                                                                    Client Specific Network –Maricopa Integrated Health System & CCF HRA Open Access Plus - 2011
Case Management
Coordinated by CIGNA HealthCare. This is a service designed to provide assistance to a 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 strives to attain a balance between quality and cost effective care while maximizing the
patient's quality of life.

Benefit Exclusions (not all-inclusive):
Your plan provides for most medically necessary services. The complete list of exclusions is provided in your Certificate or Summary Plan Description. To the
extent there may be differences, the terms of the Certificate or Summary Plan Description control. Examples of things your plan does not cover, unless required
by law or covered under the pharmacy benefit, include (but aren’t limited to):


1.    Any service or supply not described as covered in the Covered Expenses section of the plan.
2.    Any medical service or device that is not medically necessary.
3.    Treatment of an illness or injury which is due to war or care for military service disabilities treatable through governmental services.
4.    Any services and supplies for or in connection with experimental, investigational or unproven services.
5.    Treatment of TMJ disorder.
6.    Dental treatment of the teeth, gums or structures directly supporting the teeth, however, charges made for services or supplies provided for or in connection with an accidental
      injury to sound natural teeth are covered provided a continuous course of dental treatment is started within 6 months of the accident.
7.    Medical and surgical services, initial and repeat, intended for the treatment or control of obesity, including clinically severe (morbid) obesity, including: medical and surgical
      services to alter appearances or physical changes that are the result of any surgery performed for the management of obesity or clinically severe (morbid) obesity; and weight
      loss programs or treatments, whether prescribed or recommended by a physician or under medical supervision.
8.    Unless otherwise covered as a basic benefit, reports, evaluations, physical examinations, or hospitalization not required for health reasons, including but not limited to
      employment, insurance or government licenses, and court ordered, forensic, or custodial evaluations.
9.    Court ordered treatment or hospitalizations.
10.   Infertility drugs, surgical or medical treatment programs for infertility, including in vitro fertilization, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer
      (ZIFT), variations of these procedures, and any costs associated with the collection, washing, preparation or storage of sperm for artificial insemination (including donor fees).
      Cryopreservation of donor sperm and eggs are also excluded from coverage.
11.   Any services, supplies, medications or drugs for the treatment of male or female sexual dysfunction.
12.   Medical and hospital care and costs for the child of a Dependent, unless this infant child is otherwise eligible under the plan.
13.   Therapy or treatment intended primarily to improve or maintain general physical condition or for the purpose of enhancing job, school, athletic or recreational performance.
14.   Consumable medical supplies other than ostomy supplies and urinary catheters.
15.   Private hospital rooms and/or private duty nursing except as provided under the Home Health Services provision.
16.   Artificial aids, including but not limited to hearing aids, semi-implantable hearing devices, audiant bone conductors, bone anchored hearing aids, corrective orthopedic shoes,
      arch supports, elastic stockings, garter belts, corsets, dentures and wigs.
17.   Eyeglass lenses and frames and contact lenses (except for the first pair of contact lenses for treatment of keratoconus or postcataract surgery).
18.   Routine refraction, eye exercises and surgical treatment for the correction of a refractive error, including radial keratotomy.
19.   Non-prescription drugs and investigational and experimental drugs, except as provided in the plan.
20.   Routine foot care, however, services associated with foot care for diabetes and peripheral vascular disease are covered when medically necessary.
21.   Genetic screening or pre-implantation genetic screening.
22.   Fees associated with the collection or donation of blood or blood products.
23.   Cost of biologicals that are immunizations or medications for the purpose of travel, or to protect against occupational hazards and risks.
24.   All nutritional supplements and formulae are excluded, except infant formula needed for the treatment of inborn errors of metabolism.
25.   Services for or in connection with an injury or illness arising out of, or in the course of, any employment for wage or profit.
26.   Expenses incurred for medical treatment for a person age 65 or older, who is covered under the plan as a retiree, or his dependent, when payment is denied by the Medicare
      plan because treatment was not received from a participating provider of the Medicare plan.
27.   Expenses incurred for medical treatment when payment is denied by the primary plan because treatment was not received from a participating provider of the primary plan.




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Benefit Exclusions – continued:

28. The following services are excluded from coverage regardless of clinical indications: Massage Therapy; Cosmetic Surgery and Therapies; Macromastia or Gynecomastia
    Surgeries; Surgical Treatment of Varicose Veins; Abdominoplasty/Panniculectomy; Rhinoplasty; Blepharoplasty; Redundant Skin Surgery; Removal of Skin Tags;
    Acupressure; Craniosacral/cranial therapy; Dance Therapy, Movement Therapy; Applied Kinesiology; Rolfing; Prolotherapy; Transsexual Surgery; Non-medical counseling
    or ancillary services; Assistance in the activities of daily living; Cosmetics; Personal or Comfort Items; Dietary Supplements; Health and Beauty Aids; Aids or devices that
    assist with non-verbal communications; Dental implants for any condition; Telephone Consultations; E-mail & Internet Consultations; Telemedicine; Health Club
    Membership fees; Weight Loss Program fees; Smoking Cessation Program fees; Reversal of male and female voluntary sterilization procedures; and Extracorporeal Shock
    Wave Lithotripsy for musculoskeletal and orthopedic conditions.


These Are Only the Highlights
As you can see, the plan is designed to combine in-depth coverage with cost-effective prices. This summary contains highlights only and is subject to change.
The specific terms of coverage, exclusions and limitations including legislated benefits are contained in the Summary Plan Description or Insurance Certificate.
This plan is insured and/or administered by Connecticut General Life Insurance Company, a CIGNA Company.

 "CIGNA" and the "Tree of Life" logo are registered 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), 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 California, HMO plans are offered by CIGNA HealthCare of California, 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. All other medical plans in these states are insured or
administered by CGLIC or CHLIC.




Catalog Number: BSM50032 (05/2011)
(06)
2011 CIGNA




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                                                                Client Specific Network –Maricopa Integrated Health System & CCF HRA Open Access Plus - 2011

								
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