Please contact your Tribal Benefits Officer for exact rates. Important things you should keep in mind about these benefits: The Standard Option calendar year deductibles are $350 per person (limited to $700 per Self Plus One enrollment or $900 per Self and Family enrollment) for services of PPO providers and $350 per person (limited to $700 per Self Plus One enrollment or $900 per Self and Family enrollment) for services of Non-PPO providers. For that, go to Section 5 Benefits. As of January 1, 2021, all Cigna HealthcareSM Commercial pharmacy plans and Cigna Healthcare Medicare claims are adjudicating on the Express Scripts systems. Note: See Hearing services (testing, treatment, and supplies), page 41 for coverage of external hearing aids and testing to fit them. If you enroll in a Medicare Advantage plan, tell us. For more information on patient safety, please visit: Preventable Healthcare Acquired Conditions ("Never Events"), When you enter the hospital for treatment of one medical problem, you do not expect to leave with additional injuries, infections, or other serious conditions that occur during the course of your stay. For these outpatient procedures, you, your representative, your doctor or facility must call Cigna/CareAllies at 800-887-9735 before scheduling the procedure. The travel and lodging allowance will not be available. SAMBA offers you and your family a choice of two comprehensive dental plans options: the DMO Plan or the PPO Plan. Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control. In the event that you have received overpayment, please return the funds to Cigna Healthcare SM at: Cigna Healthcare P O Box 188012 Chattanooga, TN 37422 Contact Cigna/CareAllies at 800-887-9735. Any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury. High Option and Standard Option Retail: You may only obtain a 30-day supply and one refill through the Express Scripts system available at most pharmacies. If you choose a Plan-designated transplant facility, the Plan will provide an allowance for preapproved reasonable travel and lodging costs (see Travel/Lodging Benefit below). We will base our decision on the information we already have. To finda Quest or LabCorp laboratory location near you, visit our website at www.SambaPlans.com. You will then have up to 48 hours to provide the required information. It can take several attempts to quit before you're successful. Note: See Surgical procedureson page 47 for benefits for colonoscopies performed by a physician to diagnose or treat a specific condition. Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, a waiting period will not be imposed and your coverage will not be limited due to pre-existing conditions. Alternative benefits will be made available for a limited time period and are subject to our ongoing review. However, you will be responsible for the difference in cost between the brand name drug and the generic even when the physician indicates "dispense as written" (DAW). Note: You pay charges above the Plan's limit. Precertification is the process by which prior to your inpatient hospital admission we evaluate the medical necessity of your proposed stay and the number of days required to treat your condition. If you continue to use the retail pharmacy after the second fill, you will pay the entire cost of the medication. You can get more information about Medicare prescription drug plans and the coverage offered in your area from these places: (Page numbers solely appear in the printed brochure), You need prior Plan approval for certain services, The Federal Flexible Spending Account Program FSAFEDS, If your hospital stay needs to be extended, If you disagree with our pre-service claim decision, If you are hospitalized when your enrollment begins, If your provider routinely waives your cost, Differences between our allowance and the bill, Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments, Important Notice About Surprise Billing - Know Your Rights, When other Government agencies are responsible for your care, When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP), When you have the original Medicare Plan (Part A, Part B, or both). Submit claims along with Other For information on obtaining prior approval for specific services, such as transplants, see Section 3 When you need prior Plan approval for certain services. How to get information about the status of a claim. Surgery to correct a condition caused by injury or illness if: the condition produced a major effect on the members appearance and, the condition can reasonably be expected to be corrected by such surgery. Does maternity care require precertification? Through our relationship with Cigna/CareAllies, SAMBA members can participate in the Healthy Rewards Program. ", an amount set by Medicare and called the "Medicare approved amount," or. Office visits and consultations, including second surgical opinion, Visits and consultation services provided in a convenient care clinic or an urgent care center, Same day services performed and billed by the doctor in conjunction with the office visit or consultation rendered in an office, convenient care or urgent care setting, CT/CAT; MRI; MRA; NC; PET (Outpatient requires precertification. It is generally to your financial advantage to use a physician who participates with Medicare. Call us or visit our website if you have any questions about dispensing limits. High Option inpatient hospital confinement; PPO: $200 per confinement; Standard Option inpatient hospital confinement; PPO: $200 per confinement; The High Option PPO and Non-PPO calendar year deductibles are as follows: PPO: $300 per person, limited to $600 for a Self Plus One or a Self and Family enrollment. You will pay the applicable mail order copayment for each prescription purchased. Benefits are limited to 26 visits per person, per calendar year. For example: If you do not agree with OPMs decision, your only recourse is to file a lawsuit. You may be billed for services received directly from your provider. Services, drugs, supplies or equipment provided by a hospital or covered provider of healthcare services that we determine: The fact that a covered provider has prescribed, recommended, or approved a service, supply, drug or equipment does not, in itself, make it medically necessary. You will realize an immediate savings in your out-of-pocket costs when using an OAP provider due to deeper provider discounts. Call 800-MEDICARE 800-633-4227, TTY 877-486-2048. If your physician:Opts-out of Medicare via private contract,Then you are responsible for:your deductibles, coinsurance, copayments, and any balance your physician charges. Non-PPO: 45% of the Plan allowance and any difference between our allowance and the billed amount. We cannot guarantee the availability of every specialty in all areas and continued participation of any specific provider cannot be guaranteed. Your facility will file on the UB-04 form. The Health Risk Assessment (HRA) tool is available online at www.SambaPlans.com. The tool is designed to assess the member's health profile, analyze the responses and suggest how they could achieve or maintain better health. This is an excellent tool to assist you in achieving your personal health goals. They may not seek more than their governing laws allow. If your physician or hospital tries to collect more than allowed by law, ask the physician or hospital to reduce the charges. We will pay $42.25 (65% of the actual charge of $65). This Section primarily deals with post-service claims (claims for services, drugs or supplies you have already received). Note: For refills after the first two fills, you pay the same per prescription copayment/coinsurance as lists on page 74. Educational classes and nutritional therapy for self-management of diabetes, hyperlipidemia, hypertension, and obesity when: Prescribed by the attending physician, and. In counting days of inpatient care, the date of entry and the date of discharge are counted as the same day. Do not rely on this chart alone. 3. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under the state program. For Arizona Providers - Log in to Claimstat. Plan provisions, certain exclusions, eligibility requirements, and underwriting guidelines apply for each plan. Under a Self and Family enrollment, the deductible is satisfied for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $600. Lose weight and improve your health througha personalized weight loss program. Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income, you could be eligible for a new kind of tax credit that lowers your monthly premiums. Be sure you understand the instructions you get about follow-up care when you leave the hospital or clinic. APWU Health Plan Waiting could seriously jeopardize your life or health; Waiting could seriously jeopardize your ability to regain maximum function; or. Ask questions and make sure you understand the answers. Disposable needles and syringes for the administration of covered medications, such as insulin, used to treat chronic complex conditions and require special handling and close monitoring, must be obtained through Accredo, theExpress Scripts Specialty Pharmacy, Fluoride tablets, solution (not toothpaste, rinses) for children age 0-6, Folic acid supplements for women of childbearing age 400 & 800 mcg, Low-dose aspirin as preventive medication after 12 weeks of gestation in women who are who are at high risk for preeclampsia, Generic tamoxifen and generic raloxifene when they are prescribed for primary prevention in women who are at increased risk for breast cancer. If the coverage review is denied, the member is responsible for the full cost of the drug. or Payer ID 62308. even if you have been discharged. Copayments and coinsurance amounts do not count toward any deductible. In situations where the targeted drug is prescribed, doctors are notified of lower-cost generics and preferred brands. Copayments per prescription or refill are: Note: For retail purchases made at a non-Network pharmacy, you pay the same per prescription copayments/coinsurances as listed above, plus the difference in cost had you used a participating Plan network pharmacy. The diagnosis and management of genetic disease for those patients with current signs and symptoms, and for those who have been determined to have an inheritable risk of genetic disease. Know how to use your medication. If you would like to purchase health insurance through the ACA's Health Insurance Marketplace, please visit www.HealthCare.gov. In-network preferred and non-preferred brand name prescription drugs. You will pay the applicable mail order copayment for each prescription purchased. Therapies include, but are not limited to: Growth Hormones, Inflammatory Conditions, and Multiple Sclerosis. Lab Program You can use this voluntary program for covered lab services. Call If you sign such a waiver, whether or not you are responsible for the total charge depends on the contracts that the Plan has with its providers. Intensive outpatient program treatment, partial hospitalization, and electroconvulsive therapy require prior authorization to be eligible for full benefits. If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information. FEDVIP coverage pays secondary to that coverage. Especially note the times and conditions when your medication, if you reside in a state that recognizes common-law marriages, lowest-cost nationwide plan option as determined by OPM. The plan will allow two fills for short term therapy (acute specialty drugs) at a retail pharmacy. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits. Birthing center a licensed or certified facility approved by the Plan, that provides services for nurse midwifery and related maternity services. Your identification card displays their network logo that will allow you discounts and enhanced savings for 9,903 general acute care hospitals, 24,042 facilities and 4,195,466 specialists and primary care physicians and 173 transplant facilities. You can submit this form online by logging in to your account at www.express-scripts.com and locating the "Submit your claim online" link on the Forms and Cards page. The vendors that support SAMBA hold accreditations from URAC (Cigna Health Management, Inc. and Express Scripts) and the National Committee for Quality Assurance (Cigna's Open Access Plus Network). Note: We will not consider any fee charged above the Plan's allowance. Benefits are payable for up to two attempts per person, per calendar year with up to four counseling sessions per attempt. We updated language for some of those services with age and frequency requirements to a more generic format in order to comply with any changes/updates to the USPSTF recommendations that may occur mid-year. Selecting these links will take you away from Cigna.com to another website, which may be a non-Cigna website. This plan recognizes that transsexual, transgender, and gender-nonconforming members require healthcare delivered by healthcare providers experienced in transgender health. For example: Call collect charges will be accepted by Cigna. Health Benefit Plan. PPO benefits apply only when you use a participating Cigna OAP Network provider. Mini-transplants (non-myeloablative allogeneic, reduced intensity conditioning or RIC) for: Acute lymphocytic or non-lymphocytic (i.e. and "Should I Enroll in Medicare?" Such physicians are permitted to collect only up to the Medicare approved amount. For questions regarding covered providers or benefits, contact the NALC Health Benefit Plan or refer to the NALC Health Benefit Plan brochure RI 71-009 for detailed information regarding your benefits. Other separate copayments include, but are not limited to: A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for them. Please visit the Internal Revenue Service (IRS) website at www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more information on the individual requirement for MEC. 24/7 access to a secure website with helpful articles, tools, trackers, and more. Make sure your medicationis what the doctor ordered. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation. The Plan requires the Step Therapy program for Colchicine, Cox-2 inhibitors, Hypnotics, Nasal Steroids, Nonsteroidal Anti-inflammatory drugs, Ophthalmic antiallergy, Proton Pump Inhibitors, Tetracyclines, Topical Acne/Rosacea, Topical Antifungal, Topical Corticosteroids and Topical Immunomodulators. Annuitants coverage and premiums begin on January 1. We know it isn't easy to quit smoking. Conditions associated with an inborn error of metabolism interfere with the metabolism of specific nutrients. We will make our decision within 15 days of receipt of the pre-service claim. For non-urgent care claims, we will tell the physician and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have prior authorization. Contact your employing office for further information. This Program provides access to discounts on treatments and items not covered under the Plan. If your physician prescribes a new medication that will be taken over an extended period of time and you prefer to receive your maintenance medication through the mail, you should request two prescriptions one to be used for the participating Express Scripts network pharmacy and the other for Express Scripts Mail Service. If your plan terminates participation in the FEHB in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. Conditions and diseases listed in the most recent edition of the International Classification of Diseases (ICD) as psychosis, neurotic disorders, or personality disorders; other nonpsychotic mental disorders listed in the ICD; or disorders listed in the ICD requiring treatment for use of, or dependence upon, substances such as alcohol, narcotics, or hallucinogens. 360ee (b) (3)), is a food which is formulated to be consumed or administered enterally under the supervision of a physician and which is intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation. You must tell us if you or a covered family member has coverage under any other health plan or has automobile insurance that pays healthcare expenses without regard to fault. Our Plan allowance is the amount we use to calculate our payment for covered services. Contact Cigna/CareAllies at 800-887-9735. The contact details below are for customers with Individual Private Medical Insurance policies. Contact Cigna/CareAllies at 800-887-9735. call your plan's customer service representative at the phone number found on your enrollment card, plan brochure, or plan website. P.O. For more information, see Differences between our allowance and the bill in Section 4. Registration. We will begin paying benefits once the remaining portion of your calendar year deductible ($220 under High Option or $270 under Standard Option) has been satisfied. Note: If you remain on a medication longer than 60 days (i.e., initial fill plus one refill), you must obtain subsequent refills through the Express Scripts Mail Service or through the Smart90 Program as described below and on page 70. Our explanation of benefits (EOB) form will tell you how much the physician or hospital can collect from you. Contact Cigna/CareAllies at 800-887-9735. See page 110. Medications purchased through a physician's office, home health agency, outpatient hospital, or other outpatient facility: Note: To receive the Plan's maximum benefit, these medications should be purchased directly from Accredo, the Express Scripts Specialty Pharmacy. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. All pictures are used for illustrative purposes only. All insurance policies and group benefit plans contain exclusions and limitations. You can get care from any "covered provider" or "covered facility." If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option. Covered services include visits through the web or your mobile device to obtain a consultation, counseling and prescriptions (when appropriate). 12 months of continuous hormonal therapy), as determined by the plan; and 4) prior authorization for the surgery has been obtained even if the proposed treatment is outside of the 50 United States (contact Cigna/CareAllies at 800-887-9735; see Section 3, Reduction of fractures of the jaws or facial bones, Surgical correction of cleft lip, cleft palate or severe functional malocclusion, Excision of impacted teeth, bony cysts of the jaw, torus palatinus, leukoplakia, or malignancies, Excision of cysts and incision of abscessesnot involving the teeth, Other surgical procedures that do not involve the teeth or their supporting structures, Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis, Small intestine with multiple organs, such as the liver, stomach, and pancreas, Recurrent germ cell tumors (including testicular cancer), Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia, Advanced Hodgkins lymphoma with recurrence (relapsed), Advanced Myeloproliferative Disorders (MPD's), Advanced non-Hodgkins lymphoma with recurrence (relapsed), Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), Marrow failure and related disorders (i.e., Fanconi's, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia), Mucolipidosis (e.g., Gaucher's disease, metachromatic leukodystrophy, adrenoleukodystrophy), Mucopolysaccharidosis (e.g., Hunter's syndrome, Hurler's syndrome, Sanfilippo's syndrome, Maroteaux-Lamy syndrome variants), Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome), Advanced Hodgkin's lymphoma with recurrence (relapsed), Advanced non-Hodgkin's lymphoma with recurrence (relapsed), Testicular, mediastinal, retroperitoneal, and ovarian germ cell tumors, Advanced Myeloproliferative Disorders (MPDs), Marrow failure and related disorders (i.e., Fanconi's, PNH, Pure Red Cell Aplasia), Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia. Services include: PPO: $15 copayment per outpatient office visit to primary care physicians; $25 copayment per outpatient office visit to specialists (No deductible), Non-PPO:35% of the Plan allowance and any difference between our allowance and the billed amount, PPO: $20 copayment per outpatient office visit to primary care physicians; $30 copayment per outpatient office visit to specialists(No deductible), Non-PPO: 35% of the Plan Allowance and any difference between our allowance and the billed amount. Anderson, IN 46013, StateStateALAKASAZARCACOCTDEDCFMFLGAGUHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNENVNHNJNMNYNCNDMPOHOKORPWPAPRRISCSDTNTXUTVTVIVAWAWVWIWY. If the physician does not, report the physician to the Medicare carrier that sent you the MSN form. The plans described below are underwritten by ReliaStar Life Insurance Company, a member of theVoya family of companies. When a Non-PPO provider has agreed to discount their charges, our allowance is the amount that the provider has negotiated and agreed to accept for the services or supplies. Chattanooga, TN 37422 ele.innerText = year; All FEHB brochures are written in plain language to make themeasy to understand. Once enrolled in your FEHB Program Plan, you should contact your carrier directly for address updates and questions about your benefit coverage. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same year. Administered by a covered provider, such as a registered nurse or a licensed or registered dietician/nutritionist. When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care. Refer to Other services in Section 3 for prior authorization procedures. Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible. If you reside in the PPO network area and no PPO provider is available, or you do not use a PPO provider, the regular Non-PPO benefits apply. You do not need precertification in these cases: Certain services require prior authorization from us. If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you before the expiration of the original 30-day period. Note: You are the only person who has a right to file a disputed claim with OPM. Pharmacy Management and Credentialing | Cigna Healthcare Cigna may not control the content or links of non-Cigna websites. copyrightEles.forEach(function(ele) { Quick Links. The prior authorization process for organ/tissue transplants is more extensive than the normal authorization process. The pre-service claim approval processes for inpatient hospital admissions (called precertification) and for other services, are detailed in this Section. If the member does not first obtain the Plans approval, they will pay the full cost of the drug. The review will not be conducted by the same person, or their subordinate, who made the initial decision. When we are the primary payor, we will pay the benefits described in this brochure.
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