CITY OF SLIDELL S2630 NON-GRANDFATHERED BENEFIT SHEET

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1 CITY OF SLIDELL S2630 BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Standard COB Dependents Children birth to 26 No later than 365 days after the Filing Limit date expenses are incurred Mailing Address & Company. Remit claims to: CIGNA Physicians & Hospitals & Non: Mail claims to Cigna, P.O. Box Chattanooga, TN Electronic Payer ID Certain Cigna Ancillary Providers are required to file claims to the Ancillary Vendor Network If members access a Third Party Network will have remit info as follows (and reflected on ID cards): Community Health Network Cigna Mt-CHN P.O. Box 3018 Missoula, MT EDI# Mississippi Health Partners MHP Systems P.O. Box Jackson, MS EDI# Don t forget to get a copy of the Patient s ID Card for claim filing directions in order to expedite claims processing. The following facilities appear as in error on the Cigna.com website and should be excluded from Cigna as they are not participating providers for payer solution groups: - Baptist Memorial Hospital Memphis - Baptist Memorial Hospital for Women - Baptist Memorial Restorative Care Hospital - Baptist Memorial Hospital Collierville - Baptist Memorial Hospital Desoto - Baptist Memorial Hospital Tipton - Baptist Rehabilitation Hospital Germantown Pre-Existing Does not apply Utilization Review: Cigna Must precertify services listed 2 days prior to admission, Emergency admissions within 48 hours or 2 business days. Inpatient confinements*, All transplant procedures Penalty: Additional $100 *Precertification is not required for inpatient or outpatient Lab Band/Lap Sleeve surgical procedures; however, complications from Lap Band/Lap Sleeve surgical procedures will be treated as any other illness, so an inpatient admission resulting from such complications will require precertification. NOTE: Occupational Therapy, Physical Therapy and Vision Therapy visits over 20 may be covered if precertification is obtained through MedCom ( ) Provider must send Letter of Medical Necessity & all applicable notes). Pre-cert penalty does not apply. Precert for PT/OT/VT only must be obtained through MedCom. GILSBARDM-# v37-Document.doc Page 1 of 8

2 CITY OF SLIDELL S2630 BENEFIT DESCRIPTION PLAN YEAR MAXIMUM BENEFIT DEDUCTIBLE, PER PLAN YEAR NON- Unlimited Expenses applied toward the satisfaction of the amount will not be applied toward satisfaction of the Non-, and expenses applied toward the satisfaction of the Non- amount will not be applied toward satisfaction of the. Per Participant $1,500 $3,000 Per Family $3,000 $6,000 MAXIMUM OUT-OF-POCKET EXPENSES, PER PLAN YEAR Expenses applied toward the satisfaction of the out-of-pocket amount will not be applied toward satisfaction of the Non- out-of-pocket, and expenses applied toward the satisfaction of the Non- out-of-pocket amount will not be applied toward satisfaction of the out-of-pocket. Per Participant $3,500 $5,000 Per Family $7,000 $10,000 NOTE: The following charges do not apply toward the out-of-pocket expense and are never paid at 100%: N/A HEALTH BENEFITS: COPAYMENTS AND BENEFIT PERCENTAGES Accident Benefit Acupuncture (20 visits Plan Year maximum) Ambulance Ground ambulance Air or water ambulance Behavioral/Mental Health and Substance Use Disorders Inpatient Includes Residential Treatment Behavioral/Mental Health and Substance Use Disorders Outpatient Includes Partial Hospitalization Blood Chemotherapy & Radiation Therapy Chiropractic Treatment Clinical Trials (as defined by this Plan for cancer or other life-threatening diseases or conditions) Includes coverage for routine patient costs associated with participation in approved Clinical Trials only. If one or more providers are participating in a Clinical Trial, the Plan may require that the qualified individual participate in the Clinical Trial with the provider. The Plan will cover Non- providers outside the state in which the qualified individual resides only if there is not a provider conducting the same trial in state. Compression Stockings (2 per Plan Year maximum) Dental Impacted Wisdom Teeth (Covered under Medical) $40 $50 $150 : $250 per admission, then 80% after $50 $150 $250 per admission, then 60% after SMH Facility: Not Available 100%, Refer to Non-Surgical Treatment of the Spine Covered under Separate Dental Plan GILSBARDM-# v37-Document.doc Page 2 of 8

3 BENEFIT DESCRIPTION Diabetes Self-management Training Diabetic Nutritional Therapy CITY OF SLIDELL S2630 Diabetic Supplies (Limited to test strips, lancets, alcohol pads and control solutions) Diagnostic Testing (X-ray, lab and Advanced Imaging MRI, CAT, PET, nuclear stress tests, etc.) Inpatient Diagnostic Testing (X-ray, lab and Advanced Imaging MRI, CAT, PET, nuclear stress tests, etc.) Outpatient Hospital Advanced Imaging (includes MRI, CAT, PET, nuclear testing, EKG, EEG, stress tests, and mammograms & ultrasounds not included under preventive care by federal law) Low Tech X-ray and Lab Diagnostic Testing (X-ray, lab and Advanced Imaging MRI, CAT, PET, nuclear stress tests, etc.) Stand Alone Facility Advanced Imaging (includes MRI, CAT, PET, nuclear testing, EKG, EEG, stress tests, and mammograms & ultrasounds not included under preventive care by federal law) Low Tech X-ray and Lab 90%, 100%, $100 $50 $100 $50 NON- Diagnostic Testing (X-ray, lab and Advanced Imaging MRI, CAT, PET, nuclear stress tests, etc.) Office Advanced Imaging (includes MRI, CAT, PET, nuclear testing, EKG, EEG, stress tests, and mammograms & ultrasounds not included under preventive care by federal law) a $100 All other Low tech x-ray (not included in the above) and lab PCP Specialist Durable Medical Equipment Emergency Room Copay if admitted directly to Hospital from Emergency room Accident-related services Non-Accident services a $30 a $40 80%, $100 $150 $100 $150 GILSBARDM-# v37-Document.doc Page 3 of 8

4 CITY OF SLIDELL S2630 BENEFIT DESCRIPTION Extended Care/Skilled Nursing Facility (60 days Plan Year maximum) Foot Conditions Physicians' services in connection with corns, calluses or toenails are excluded, unless the charges are for the partial or complete removal of the nail roots. Routine foot care and foot orthotics are not covered Gastric Bypass Hearing Aids (Limited to children up to age 18) ($1,400 per ear once every 3 Plan Years) Cochlear implants are not covered. Hearing Screening Home Health Care Hospice Care Bereavement Counseling by Hospice provider. For other bereavement counseling services refer to Behavioral/Mental Health and Substance Use Disorders Outpatient Hospital / Facility Inpatient Room and Board is limited to the semiprivate room rate, or if the Hospital has private rooms only or if a semi-private room is not available, 90% of the average private room rate. ICU as billed, Hospital / Facility- Outpatient Outpatient Surgery All other services (Except Advanced imaging, Lab, and X-Ray) Infertility/Sterility : 80%, SMH Facility: NON- Refer to Lap Band/Lap Sleeve 100%. Deductible Refer to Preventive Care Benefit : $250 per admission, then 80% after SMH Facility: $100 per admission, then $250, per admission, then 60% after $100 GILSBARDM-# v37-Document.doc Page 4 of 8

5 BENEFIT DESCRIPTION CITY OF SLIDELL S2630 Lap Band/Lap Sleeve (Limited to Eligible Employees & Eligible Retirees) (Precertification is not required for inpatient or outpatient Lap Band/Lap Sleeve surgical procedures) NON- Initial visit, screening and blood tests Psychiatric evaluation Pre-surgery Surgery (Facility fee) Surgery (Physician s fee) Post-surgery follow-up and adjustments For complications of Lap Band/Lap Sleeve surgical procedures, see applicable services for benefits. Maternity Maternity related expenses for dependent children are not covered, except as required by federal law. Prenatal care as required by federal law Other Office Services Other eligible charges $30 $50 $40 $100 $ %, Refer to Preventive Care 100% no Refer to applicable service for benefits Refer to Preventive Care Refer to applicable service for benefits. Newborn Care (routine inpatient) (Coverage includes circumcisions) Non-Surgical Treatment of the Spine (20 visits Plan Year maximum) (OV & X-ray not included in the Plan Year maximum) Obesity Limited to non-surgical treatment for obesity. Refer to Lap Band/Lap Sleeve for surgical benefits. Refer to plan document for further limitations & exclusions. Oncotype DX Covered at Genomic Health Facility only. Further limited to procedure codes and Organ Transplants Provider should notify Customer Contact Center prior to starting any transplant services, including initial evaluation. Case Management is strongly suggested. Refer to plan document for limitations & exclusions. Orthotics / Prosthetics (Foot orthotics are not covered) Physician Services- Inpatient Visits Physician Services- Inpatient Surgeon $40 $40, then GILSBARDM-# v37-Document.doc Page 5 of 8

6 BENEFIT DESCRIPTION CITY OF SLIDELL S2630 Physician Services- Outpatient Visits (services other than in a Physician s office) Physician Services- Outpatient Surgeon (services other than in a Physician s office) Physician Services: Office Visits Copay is per provider and applies only to the following: office visit charge, inoffice vasectomies, lab and low-tech x-ray, injections, supplies, minor office surgery, and allergy treatment. Additional will apply to Advanced imaging services. Refer to Diagnostic Testing benefits. Primary Care Physician Specialist Allergy Testing $30 $40 NON- All other eligible expenses rendered in the physician s office not covered under. PCP is defined as: Family Practitioner, General Practitioner, Nurse Practitioner, Internist, OB/GYN, Pediatrician and Physician Assistant. Physician Services- In-office Surgeon Prescription Drugs Inpatient Prescription Drugs Outpatient Refer to Physician Services: Office Visits Refer to Physician Services: Office Visits Refer to Hospital / Facility Inpatient Refer to Prescription Drug Benefits schedule and section GILSBARDM-# v37-Document.doc Page 6 of 8

7 CITY OF SLIDELL S2630 BENEFIT DESCRIPTION Preventive Care Benefit Evidence-based items or services with an A or B rating recommended by the United States Preventive Task Force; Immunizations for routine use in children, adolescents, or adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; these can be done at the pharmacy (refer also to Prescription Drug Benefits schedule and section) Evidence-informed preventive care and screening provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA) for infants, children, and adolescents; and Other evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by HRSA for women. Routine physical exam (1 per Plan Year), including related diagnostic tests performed during the same visit. Routine lab work All immunizations, including HPV Vaccine, covered per CDC Guidelines Gynecological exam and pap smear (1 per Plan Year) One prostatic/testicular exam & PSA for insureds 50 years of age or older, or as recommended by the Physician if the insured is 40 years of age or older Colon exam Hearing screening (1per Plan Year) Mammogram 1 per Plan year Colorectal screening routine cancer screen shall mean a fecal occult blood test, flexible sigmoidoscopy or colonoscopy as provided in accordance with the most recently published recommendations established by the American College of Gastroenterology, in consultation with the American Cancer Society, for ages, family histories, and frequencies referenced in such recommendations. Routine colorectal cancer screening shall not mean services otherwise excluded from benefits because the services are deemed by the Plan Administration to be investigational or experimental NON- 100% no Breast pumps are l limited to one per Plan Year Private Duty Nursing (Limited to Outpatient only and 60 visits Plan Year maximum) Rehabilitation Services (Cardiac Rehab, Occupational, Physical, Speech and Vision Therapies) Provider must send letter of medical necessity and all applicable notes Cardiac Rehab limited to phases I & II. Limited to 36 visits per Plan Year. Additional visits may be covered if precertification is obtained through MedCom ( ) Occupational Therapy 20 visits Plan Year maximum, additional visits may be covered if precertification is obtained through MedCom ( ) Physical Therapy 20 visits Plan Year maximum, additional visits may be covered if precertification is obtained through MedCom ( Speech Therapy 20 visits Plan Year maximum. Includes services for speech loss and developmental delays. Vision Therapy 20 visits Plan Year maximum, additional visits may be covered if precertification is obtained through MedCom ( Sleep Disorders Covered only if medically necessary Sleep Study Other eligible expenses Smoking Cessation $30 Refer to applicable service for benefits Refer to applicable service for benefits 100%, GILSBARDM-# v37-Document.doc Page 7 of 8

8 BENEFIT DESCRIPTION Sterilization CITY OF SLIDELL S2630. NON- Vasectomy (See Physician Services: Office Visits for services performed in the office) Refer to Preventive Refer to Care Female Sterilization as required by federal law Preventive Care Temporomandibular Joint Syndrome Urgent Care Facility (includes all covered charges billed by facility, except advanced imaging) $30 $30 (Additional will apply to Advanced imaging services. Refer to Diagnostic Testing benefits.) Vision Exam (1 per Plan Year maximum) $40 $40 Frames, glasses and contacts are not covered. Wig After Chemotherapy ($500 Lifetime maximum) PRESCRIPTION DRUG CARD OPTION Pharmacy Benefits Manager: PBI/Caremark. Prescription Drug Deductible Deductible must be satisfied before benefits will be paid; Deductible is for Generics and Prescribed Preventive Medications and Contraceptives as required by federal law. Per Participant, per Plan Year $50 Per Family, per Plan Year 3 per family Prescription Drug Card Options Copayment Benefit Percentage Retail Pharmacy Option (30-day supply) Prescribed Preventive Medications and Contraceptives as required by federal law. Subject to existing brand costs if a generic both exists and is allowed by the physician. $0 100% Generic drug $5 100% Formulary Brand Name drug $20 100% Non-Formulary Brand Name drug $50 100% Mail Order Option (90-day supply) Prescribed Preventive Medications and Contraceptives as required by federal law. Subject to existing brand costs if a generic both exists and is allowed by the physician. $0 100% Generic drug $10 100% Formulary Brand Name drug $40 100% Non-Formulary Brand Name drug $ % GILSBARDM-# v37-Document.doc Page 8 of 8

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