MEDICAL CIGNA PPO

**FREQUENTLY ASKED QUESTIONS**

> **What does PPO stand for?**
>
> Preferred Provider Organization **--** this type of insurance allows
> the employee to choose any health care provider. If the provider is
> in-network, there is a savings to the employee.
>
> **How do I find an in- network physician?**
>
> Call Customer Service at 1-800-244-6224, or look up the directory
> listing on Cigna's web site address at
> [www.cigna.com](http://www.cigna.com/) or pick up a directory at the
> Benefits Office.
>
> **Do I have to select a physician that is in the network?**
>
> No, you may select any physician you want, but keep in mind there is a
> substantial savings to you when you go in-network.
>
> **What is the difference between in-network versus out-of-network?**
>
> In the in-network arrangement the physician or health provider has a
> contract with Cigna PPO insurance that specifies the amount of
> discount they will give for a medical procedure. The cost savings is
> passed on to the employee and Fermilab.
>
> In the out-of-network arrangement the physician or health provider
> does not have any type of contractual agreement with Cigna PPO. No
> type of discount is given on a medical procedure and there is no cost
> savings passed on to either you or Fermilab.
>
> **Can each family member have a different physician?**
>
> Yes, family members can select their own physician in-network or
> out-of network.
>
> **What is the cost to go to a physician who is in-network?**
>
> If the physician is in-network you pay a \$15 co-pay.
>
> **What is the cost to go to a physician who is out-of-network?**
>
> If the physician is out of-network, you must have met your deductible
> of \$500 per calendar year and then Cigna will pay for 80% of
> reasonable and customary charges and you are responsible for the
> remainder of the claim, which at the minimum would be 20% of the
> claim, but could be higher.
>
> **What is a reasonable and customary charge?**
>
> They are charges that fall within what is standard for that service or
> supply in the geographic area where the service is performed. The rate
> is set by Cigna.
>
> **Is a referral required to go to a specialist?**
>
> No, you can choose any specialist that you desire and you are not
> required to have a referral. The preceding payment schedule applies.
>
> **Do I need preauthorization to be admitted to a hospital?**
>
> Yes, you need preauthorization for hospital admissions. The number to
> call is 1-800-244-6224.

**What are the co-pays for prescription drugs?**

Pharmacy 30 day supply Mail order 90 day supply

Generic \$10 \$20

Preferred brand \$20 \$40

Non-preferred brand \$40 \$80

> To obtain a listing of medications and how they are classified, go to
> Cigna's website address at [www.cigna.com](http://www.cigna.com/)
>
> **How do I obtain information about prescriptions by mail?**
>
> CIGNA offers home delivery of prescription medications through CIGNA
> Tel-Drug. The forms are available on Cigna's website address at
> [www.cigna.com](http://www.cigna.com/) or you can pick up the
> information in the benefits office.
>
> **How do I add or delete a dependent?**
>
> Information is provided in the URA/ Summary Plan Description under the
> Medical Section on page 10. This is available at the Benefits website
> at <http://lss.fnal.gov/benedept/forms.html>. You will need to visit
> the Benefits Office to complete a Fermilab Benefit Action Form to
> enroll the new dependent or to delete a dependent.
>
> **How do I handle a case where Cigna states that my dependent has been
> terminated from the medical insurance plan?**
>
> You will need to contact the benefits office to correct the problem.

**What should I do if I lose my card?**

Call Cigna at 1-800-244-6224 to obtain another card.

**How do I file a claim?**

In network claims do not require a claim form. Your physicians' office
should electronically submit the claim to Cigna.

For out-of-network claims, either the physician's office can submit the
claim or you can submit it yourself directly to Cigna by completing the
Cigna claim form.

**How can I obtain a claim form?**

> The forms are available on their website address at
> [www.cigna.com](http://www.cigna.com/), or you can pick up the forms
> in the benefits office or print one off our Benefits website at
> <http://lss.fnal.gov/benedept/forms.html>
>
> **How long will it take to process my claim?**
>
> Upon the receipt of the claim at Cigna, it takes about 15 days to
> process your claim.
>
> **How will I know that my medical claim has been processed?**
>
> You will receive an explanation of benefits (EOB) statement. This
> statement is a confirmation that a claim has been processed and it
> will provide detailed information about deductibles, co- insurance and
> adjustments that have been taken.
>
> **How can I obtain another copy of the EOB?**
>
> You register with Cigna to have access to your personal information at
> their website address at [www.cigna.com](http://www.cigna.com/) or
> call Member Services at 1-800-244-6226.
>
> **Up to what age is my dependent child covered?**
>
> Your dependent child can be covered if they are unmarried, primarily
> supported by you and less than 19 years old. If the dependent child is
> a full time student, they can continue to be covered until the day of
> their 23^rd^ birth date.
>
> **How does COBRA work in relation to my medical benefits?**
>
> Please refer to the URA/ Summary Plan Description under the medical
> section on pages 11 -12 for all of the details. This is available at
> the Benefits website at <http://lss.fnal.gov/benedept/forms.html>
>
> **What is a deductible?**

The amount of eligible out of pocket expenses you must pay each calendar
year before Cigna pays for specific benefits.

> **Which benefits are subject to a deductible?**
>
> Please refer to the URA/Summary Plan Description under the medical
> section on page 4 for details or Cigna's PPO medical certificate. This
> is available at the Benefits website at
> <http://lss.fnal.gov/benedept/forms.html>
>
> **What is the annual deductible for individual and family?**

The deductible for in-network is \$250 per person and the maximum is
\$750 for 3 family members per calendar year. For out-of-network the
deductible is \$500 per person and \$1500 for 3 family members.

> **After the deductible has been met, what is the level of coverage?**
>
> In-network claims will be paid at 90% of the claim and you are
> responsible for 10% and out-of network claims will be paid at 80% and
> you are responsible for 20%
>
> **What is the maximum out of pocket expense that I am responsible
> for?**
>
> The out-of pocket is \$1,500 per person and \$4,500 per family for
> in-network and \$3,000 per person and \$9,000 for family for
> out-of-network. Once you have met the maximum out of pocket expenses,
> the rest of the eligible claims for that calendar year are covered at
> 100%.
>
> **What is not covered as an out of pocket expense?**
>
> Your co-pays and deductibles are not covered under the out of pocket
> limit.
>
> **Is an annual physical covered?**

When you go to an in-network provider, you pay \$15 co-pay and up to
\$300 of expenses are covered at 100%. An annual exam is not covered
when you go to an out-of-network provider.

> **Are eye exams covered?**

An eye exam is covered only when the office visit is for a disease of
the eye and not an exam to obtain a prescription for glasses.

> **Is there a lifetime maximum coverage?**
>
> You are subject to a lifetime maximum of \$2,000,000; it is cross
> accumulated between in-network and out-of-network. This is applied to
> each individual member.

**How can I obtain information about the appeals or grievance
procedure?**

> The process can be reviewed in the URA/Summary Plan Description under
> the medical section for active and retired employees on page 16, in
> your certificate book or on Cigna's website at
> [www.cigna.com](http://www.cigna.com/)