Health Plan. Administered by. Allegiance Benefit Plan Management, Inc. P.O. Box 3018 Missoula, MT

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1 Welcome to Your Health Plan Administered by Allegiance Benefit Plan Management, Inc. P.O. Box 3018 Missoula, MT Please note: This booklet is not a plan document or summary plan description (SPD) as those terms are defined by federal law but rather just key highlights of your plan. The outline of benefits contained in this booklet are subject to change by the Plan Administrator. Please refer to your actual SPD for the terms and conditions regarding the payment of a claim. If there is any difference between this booklet and the SPD, the SPD will control.

2 Identification Cards Dear Plan Member: Welcome to your Health Plan administered by Allegiance Benefit Plan Management (Allegiance). We offer the highest quality service in claims administration and management. You will be receiving a new identification card(s) (ID cards) for your Health Plan in the mail in August. You will receive one card if you elected single coverage. If you elect dependent coverage, you will receive an ID card for yourself and one for each dependent over the age of 18. These cards are important as they contain your group number and provide claims filing information. It is your responsibility to inform your health care providers of the information on the ID card. Please present your Allegiance ID card each time you visit a provider. Important Features to Notice on Your ID Card: 1 Group ID Number Allegiance uses a randomly generated 12 digit ID number as your Employee ID NO. The number is printed on your ID card. Please show your providers your new ID card. Your providers will submit this ID number on claims rather than your social security number. 3 Our website is The website can provide you with status of health claims, a summary of recent online activity, and direct links to a provider search website for lists of participating providers and their locations. You can also request a health plan ID card, apply for a health plan Certificate of Creditable Coverage, or process an address change. 4 The address for claims submission is on the back of the ID card. Most providers will bill Allegiance directly on your behalf. If you need to submit a claim, please mail to Cigna 1000 Great West Drive Kennett, MO , unless otherwise noted on the back of your card hour verification of coverage is available through our Interactive Voice Response (IVR) faxback system at (406) Your Allegiance toll-free Customer Service number is Please keep in mind the phone line may not be open until closer to your effective date.

3 Identification Cards 7 Pre-Certification is required before admission on all scheduled outpatient surgical procedures or inpatient hospital stays. You should report all emergency admissions within 72 hours. Refer to your Summary Plan Description booklet for complete pre-notification information. Contact StarPoint Healthcare Group, your healthcare management organization, at to pre-certify inpatient admissions and Customer Service at to notify of scheduled outpatient procedures. Please present your new ID card to your health care providers and pharmacy to prevent any disruption with your claims. 8 For pharmacy coverage, you will see a SXC logo on the back of your card. The BIN/PCN numbers, employee s ID number Your card may not be identical to the sample card. Certain aspects, such as PPO logos, vary for different locations. and patient s date of birth, is all the pharmacy will need to process your prescription claims. The SXC Customer Service line is: Please be advised that this line will not be open until your effective date of 9/1/ For medical coverage, you will see Network logos on your card. Your health benefit ID card has the logo for the CINGA Open Access Plus Network that you can access. If you have any questions with regards to your new ID card please call Customer Service at

4 Schedule of Benefits Core Medical Plan

5 Schedule of Benefits Core Medical Plan

6 Schedule of Benefits Core Medical Plan

7 Schedule of Benefits Basic Medical Plan

8 Schedule of Benefits Basic Medical Plan

9 Schedule of Benefits Basic Medical Plan

10 Schedule of Dental Benefits

11 Schedule of Vision Benefits

12 Employee Assistance Program

13 EAP (cont.)

14 Network Providers Network Providers What is a network provider? Your plan will access In network services through the Cigna Open Access Network. This national network includes local physicians and health care professionals in your area. Network providers agree to file claim forms on behalf of enrollees and accept the contracted maximum allowable fees as payment in full with no balance billing. You will be responsible for any remaining balance over what the plan has paid, but only up to the contracted maximum allowable expense that the provider has agreed upon. You may also be responsible for paying a deductible and any applicable copayments. Advantages of Using the Network: As a plan participant, you are free to go to any provider you choose for services covered by the plan. However, by utilizing network providers you can save on out of pocket expenses. The amount of money you may save by using the network will vary depending on the provider, the service provided, and the details of your health benefit plan. You are not required to use a preferred provider but if you obtain service from an out of network provider you may be responsible for those amounts which are in excess of the usual, customary and reasonable charges in the area where the service was provided. Some plans, known as differential plans, pay at a higher benefit level when a network provider is used. Using an in network provider from the Open Access Network may not always ensure a discount, but your claim will be processed at the higher benefit level. How to Access the Network: You can access information regarding contracted providers in your area by calling the customer service line and request the names of providers in your area. Or perform a provider search on the internet: 1. Log on to 2. Click on the Find a Doctor link. 3. Select the way you would like to search a provider. 4. Under Select a Network click Open Access Plus/Open Access. 5. Fill out the search fields and click Submit. 6. A list of provider according to your criteria will pull up. Please note that the network listing of PPO or Network Providers is subject to change without notice. Before receiving services, please verify with the provider that he/she is still a participating provider.

15 A larger print-ready version of this form is available on our website at:

16 General Questions Claims Procedure In most instances all you will need to do is present your new ID card to your physician, hospital, or other health care provider. Most providers will take the claims information from your new card and bill Allegiance directly. Service Questions If you have a benefit question you may call our Customer Service Department at The Customer Service Department is available from 6:00 am to 6:00 pm Mountain time. Our staff will be available to assist you with any questions or problems you may have. If your question is whether or not a claim has been received and what the status is, there are two other options to access that information which are available 24 hours a day, seven days a week. The first is our Interactive Voice Response (IVR) system. You may call to reach an auto-attendant and from there option 2 will access the IVR system. Follow the voice prompts to check on your claim. You will need the 12 digit identification number of the employee and the date of service for the claim to complete the inquiry. The other option is to sign up for Internet access to your claims data. That process is described in detail on the next page. COBRA Please refer to the section in your Summary Plan Description (SPD) booklet on Continuation of Coverage (COBRA) for your rights and responsibilities for continued health plan coverage upon loss of coverage. These COBRA rights may apply to you and your covered dependents and may vary depending on the number of employees in your company and the state where you live. Please consult your Summary Plan Description for complete COBRA information. The Allegiance Toll-free Customer Service number is:

17 Online Services At Allegiance, our number one priority is taking care of our members. We offer broad access while maintaining security on Allegiance s state-of-the-art website, putting benefits and claims information at your fingertips. Our online website offers personalized services at the click of a mouse. By registering, you will have 24 hour a day access to information regarding your health plan. You can check the status of a claim, review coverage and benefits, and verify who is covered under your plan. You can even view your plan document and review the most frequently asked questions. Follow these steps to register. Please note that you cannot create a login until after you are effective on the plan. 1. Log onto 2. Select Employee Login/ Employer Login 3. If you ve already visited this Web site, enter your username and password, check the privacy policy box and click login. 4. If you have never logged into the site, you will need to click Register New User on the Login page. 5. This will prompt you to create a Username of 1-20 case sensitive characters. You will also need to enter your address and mark what type of user you are. Click Next. 6. The next screen will ask you to validate some information. If your information entered does not match the Allegiance database or you previously created a login, you will receive an error stating a login could not be created. Please double check the information you entered. If everything was entered correctly, contact Allegiance for assistance at option 4. M-F 6am-6pm MST. 7. Once you have successfully matched your personal information to the system, you will be prompted to create a Password (also case sensitive) as well as a password hint. 8. Once this step is completed, you will be logged into your personal benefit site. The Allegiance Web Address is:

18 StarPoint Healthcare Group/ Nurse Line As part of your health benefit plan, you are enrolled in a managed care program. StarPoint Healthcare Group contracts with your health plan to review services for medical necessity determinations, according to the terms of your plan. A certification from StarPoint, however, is not a guarantee of payment. Check your plan booklet for notification information. You are encouraged to call StarPoint once an admission date has been scheduled. The StarPoint nurse reviewer will initiate the certification process and will answer your questions. After your hospital discharge, a StarPoint case management nurse will assist with any questions or follow-up health care needs you may have. Pre-Notification: Pre-notification is required for all inpatient hospital admissions so that medical necessity can be established before services are rendered. Emergency Notification: Notification is required within 72 hours for emergency admissions and for observation stays when the stay exceeds 23 hours. Continued Stay Review: StarPoint will contact the hospital on your anticipated release date to confirm discharge. If you require continued hospitalization, a StarPoint nurse will work with the hospital to identify medical necessity and extend days as appropriate. StarPoint s Utilization Management Toll-free Number is: /7 Nurse Line A Nurse line is available 24 hours a day to provide health advice and information concerning your family. Call the nurse line to speak to a registered nurse at no cost For questions on health conditions like asthma, diabetes or hypertension When you need help deciding if you should see a doctor or go to the Emergency Room If you want more information on a medical test or procedure For answers to health questions any time of day even on weekends and holidays! Nurse Line Toll-Free Number:

19 Case Management / Maternity Management StarPoint is committed to providing you with case management that will best meet your needs. The Case Manager may assist you with a variety of services, some of which are listed below: Provide education on your medical condition. Work with you, your family, and health care providers to support your physician s plan of care. Provide coordination and access to appropriate health care treatment and community resources. Assist in the assessment process to help ensure that you receive the most appropriate treatment and least restrictive level of care. Your case manager will be in regular contact with you by phone and will provide written information upon your request. To learn more about case management services, call the toll-free number below. StarPoint s Case Management Toll-free Number is: StarBaby is your health plan s maternity management program. This program offers pregnancy-related information and support from a personal Registered Nurse (RN) that is available to talk with you throughout your pregnancy and afterwards. The program is FREE TO YOU and will provide you with: Important pregnancy-related information Support and assistance from a Registered Nurse A Post Pregnancy Assessment A pregnancy related book or $25 gift card For more information or to register for the program, please call the toll-free number below or go online to and click the Get Secure Access link. StarBaby Toll-free Number is: Or register online at Starpointmedical.com

20 Important Contact Information Allegiance Dedicated Customer Service: Allegiance Online Services: Claims Submission Address: Cigna 1000 Great West Drive Kennett, MO hour Faxback Verification of Coverage: or (406) SXC Pharmacy: StarPoint Utilization Management/ Pre-Notification Review: StarPoint Case Management/ StarBaby Maternity Management , Option /7 Nurse Line Alliance Work Partner EAP