Learn More. The Peer-to-Peer request must be received by Maryland Amerigroup maryland prior authorization Care within two 2 business days of the initial notification of the denial. The intent of the Peer-to-Peer is to discuss the denial decision with the ordering clinician or attending physician. For specific details prioe authorization requirements, please refer to our Quick Reference Guide. Certain carefirst mental providers require prior authorization regardless of place of service.
Outside of low-value PSA cancer screening, other studies have documented care cascades of low-value services. A recent Canadian study found that 3 low-value preventive services ie, chest radiograph, electrocardiogram, and Papanicolaou test increased the likelihood of having more subsequent visits related to the initial low-value service.
Our study has limitations. Nevertheless, some PSA screening and downstream services in this population could be deemed necessary and not be considered low-value. Claims data do not provide sufficient clinical context and nuance to determine the necessity of the services provided, such as symptoms individuals are experiencing, results from testing, and why clinicians ordered particular services.
Also, our study sample is limited to a privately insured Medicare population. Although PSA cancer screening rates in our sample were similar to those reported in other studies that included beneficiaries enrolled in either traditional Medicare or other Medicare Advantage plans or those who were dual-eligible, 35 the overall spending estimates would likely be different among traditional Medicare and Medicare Advantage populations.
Additionally, we may have underestimated wasteful spending associated with care cascades of low-value PSA cancer screening by excluding other costs beyond the procedure costs, such as the office visit, facility, and physician fees for surgical procedures. Also, the rapidly increasing costs of imaging in recent years eg, attributed to the use of multiparametric magnetic resonance imaging [mpMRI] for evaluating elevated PSAs and more expensive fusion biopsies using mpMRI images are not captured in our data from to , which could be another reason for underestimation.
Despite multiple guidelines recommending against its routine use in men age 70 years or older, a third of men in this group received a low-value PSA test for prostate cancer screening. More than half of those screened received subsequent follow-up services, mostly repeated PSA testing, leading to potential harm and additional unnecessary expenditures.
Because guideline recommendations alone might not lead to long-term sustained effects of reducing low-value PSA cancer screening, 40 innovative and perhaps harsher efforts to reduce both initial unneeded care and avoidable cascading effects—such as the implementation of Section of the Patient Protection and Affordable Care Act, which provides the Secretary of Health and Human Services the authority to provide no payment for USPSTF grade D services—may be warranted to decrease harm, enhance equity, and improve efficiency of medical spending.
Published: November 22, Corresponding Authors: David D. Author Contributions: Dr Kim had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Critical revision of the manuscript for important intellectual content: Daly, Koethe, Fendrick, Ollendorf, Wong, Neumann. Dr Ollendorf reported receiving personal fees from BioMarin, G1 Therapeutics, Atheneum Consulting, the Center for Global Development, the Inter-American Development Bank, Gilde Healthcare, and Eli Lilly and Co outside the submitted work; he is employed by a research center that receives sponsorship funding from life sciences companies, government agencies, and academic institutions to develop and maintain a variety of databases.
No other disclosures were reported. Additional Contributions: We appreciate Aaron L. He was compensated for his time. Download PDF Comment. Figure 1. View Large Download.
Figure 2. Figure 3. Table 1. Table 2. The cascade effect in the clinical care of patients. Cascade effects of medical technology. Cascades of care after incidental findings in a US national survey of physicians. To expand the evidence base about harms from tests and treatments.
An evidence review of low-value care recommendations: inconsistency and lack of economic evidence considered. Center for Value-Based Insurance Design. Low-value care. Accessed June 29, Evidence for overuse of medical services around the world.
Measuring low-value care in Medicare. Payer type and low-value care: comparing Choosing Wisely services across commercial and Medicare populations.
Low-value service use in provider organizations. Trends in low-value health service use and spending in the US Medicare fee-for-service program, Trends in use of low-value care in traditional fee-for-service Medicare and Medicare Advantage. Early trends among seven recommendations from the Choosing Wisely campaign. Development of a conceptual map of negative consequences for patients of overuse of medical tests and treatments.
Prevalence and cost of care cascades after low-value preoperative electrocardiogram for cataract surgery in fee-for-service Medicare beneficiaries. Patterns of clinical care subsequent to nonindicated vitamin D testing in primary care. Assessment of prevalence and cost of care cascades after routine testing during the Medicare annual wellness visit. Longitudinal content analysis of the characteristics and expected impact of low-value services identified in US Choosing Wisely recommendations.
Early detection of prostate cancer: AUA Guideline. Screening for prostate cancer: a guidance statement from the Clinical Guidelines Committee of the American College of Physicians.
Enthusiasm for cancer screening in the United States. Prostate cancer screening with prostate-specific antigen PSA test: a systematic review and meta-analysis. Preoperative serum prostate specific antigen levels between 2 and 22 ng.
Low-value prostate cancer screening among older men within the Veterans Health Administration. Accountable care organizations and the use of cancer screening.
Factors associated with low-value cancer screenings in the Veterans Health Administration. Prostate cancer: screening. Updated May 8, Accessed April 30, What happens after an elevated PSA test: the experience of 13, veterans.
Prostate cancer screening in the randomized Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial: mortality results after 13 years of follow-up. Five-year downstream outcomes following prostate-specific antigen screening in older men. The cost implications of prostate cancer screening in the Medicare population. Choosing wisely: prevalence and correlates of low-value health care services in the United States.
For selected services, Blacks and Hispanics more likely to receive low-value care than Whites. State-level variation in low-value care for commercially insured and Medicare Advantage populations. Association of low-value testing with subsequent health care use and clinical outcomes among low-risk primary care outpatients undergoing an annual health examination.
Coinsurance — The amount or percentage that you pay for certain covered healthcare services under your health plan. This is typically the amount paid after a deductible is met, and can vary based on the plan design. Copayment — The flat fee that you pay towards the cost of covered medical services.
Covered Expenses — Healthcare expenses that are covered under your health plan. Deductible — Before benefits are available through a health plan, you must pay a specific dollar amount out of pocket. Under some plans, the deductible is waived for certain services. Dependent — Individuals who meet eligibility requirements under a health plan and are. You determine how much you want to contribute to the FSA at the beginning of the plan year.
You cannot go outside of the network. Contributions can be made by both you and your employer. The money is deducted from your paycheck pre-tax and deposited in the account. Balances carry from one year to the next, and the account belongs to you. Withdrawals for non-medical expenses are subject to income taxes, and an additional penalty if age 65 or under. High-Deductible Health Plan HDHP — A qualified health plan that gives you more control over your health care spending by offering lower monthly premiums in exchange for higher deductibles and out-ofpocket limits.
In-Network — Care received from your primary care physician or from a specialist within an outlined list of health care practitioners. Inpatient — A person who is treated as a registered patient in a hospital or other health care facility. This person accrues room and board charges. Out-of-Network — Care you receive without a physician referral or services received by a non-network service provider.
Out-of-network healthcare and plan payments are subject to deductibles and copayments. Out-of-Pocket Expense — Amount that you must pay towards the cost of healthcare services. This includes.
Both the deductible and the coinsurance apply towards meeting the OPM, but copayments may not apply. Under some plans, the deductible and OPM may have the same dollar limit. Point of Service Plan POS — Insurance plan where you have two options: 1 stay within the network of doctors or 2 go outside the network. There are additional costs should you choose to go outside of the network. Preferred Provider Organization PPO — Insurance plan, similar to a point of service plan, where you have two options: 1 stay within the network of doctors or 2 go outside the network.
Premium — The amount you pay for a health plan in exchange for coverage. Health plans with higher deductibles typically have lower premiums. This generally includes family practice physicians, general practitioners, internists, pediatricians, etc. Usual, Customary and Reasonable UCR Allowance — The fee paid for covered services that is: 1 a similar amount to the fee charged from a healthcare provider to the majority of patients for the same procedure; 2 the customary fee paid to providers with similar training and expertise in a similar geographic area, and 3 reasonable in light of any unusual clinical circumstances.
Ambulance if medically necessary Hospitalization-Members are responsible for applicable physician and facility fees Outpatient Facility Services. Once annual Once annual Once annual Once annual deductible is met, deductible is met, deductible is met, deductible is met, then copay until then copay until then copay until then copay until out-of-pocket max out-of-pocket max out-of-pocket max out-of-pocket max is reached is reached is reached is reached. Version 10 1 of 7. Includes related supplies.
This benefit does not cover the related Facility or Professional charges. This benefit does not cover the related Office Visit or Professional charges.
This benefit does not cover the related Professional charges. Retail drugs for a 30 day supply may be obtained In-Network at a wide range of pharmacies across the nation although prescriptions for a 90 day supply such as maintenance drugs will be available at select network pharmacies.
Specialty Drugs may include high cost medications as well as medications that may require special handling and close supervision when being administered. If you choose to fill a 30day prescription, it can be filled at any network retail pharmacy or Cigna Home Delivery. If you choose to fill a day prescription, it must be filled at a day network retail pharmacy or Cigna Home Delivery to be covered by the plan.
Some exceptions may apply. To check which drugs are included in your plan, please log on to myCigna. 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. For children, you may designate a pediatrician as the primary care provider. 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 preapproved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, visit www.
Network providers are contractually obligated to perform pre-authorization on behalf of their clients. If there are any differences between this summary and the plan documents, the information in the plan documents takes precedence.
Version 10 1 of 8. Version 10 2 of 8. Includes related supplies Benefits Hospital Services. Mental Health and Substance Use Disorder. Version 10 3 of 8. Version 10 4 of 8. Version 10 5 of 8. The applicable cost share for covered drugs applies after the combined deductible has been met.
Version 10 6 of 8. Out-of-network services are subject to a plan year deductible and maximum reimbursable charge limitations. Complete Care Management Pre-authorization is required on all inpatient admissions and selected outpatient procedures, diagnostic testing, and outpatient surgery.
Network providers are contractually obligated to perform pre-authorization on behalf of their customers. For an out-of-network provider, the customer is responsible for following the pre-authorization procedures. Version 10 7 of 8. Version 10 8 of 8.
Cigna will send your enrollment information to BenefitWallet. Complete your account opening by using Advantage Direct. If you did not use Advantage Direct to open your account during enrollment, you will need to complete the account opening online or return the signature card to BenefitWallet.
If you wish to order the optional checkbook, you will need to return the signature card. You will receive your debit card directly from Cigna. Activate your card. To request a card for another person in your family, visit myCigna. Begin making payroll contributions to your HSA account via your employer if available or directly via check or electronically. Remember, your bank account must be open before funds can be deposited into your HSA. Register on myCigna.
From myCigna. Start paying for qualified expenses with your HSA dollars or use the money for future expenses. Tiered interest rate tied to account balance. You can request additional cards on myCigna.
Once you are enrolled and your account is open, you will have access to your account balances and transactions, including debit card transactions, from myCigna. You will also have seamless access to the BenefitWallet website from myCigna. Prior to enrollment, for access to tools and resources including HSA calculators and a library of videos and educational resources, go to mybenefitwallet.
Standard mobile phone carrier and data usage charges apply. You are encouraged to discuss these strategies with a professional financial planner and tax advisor. Cigna is not responsible for any aspects of the HSA services, administration and operation.
Some content provided under license. Cigna does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. If you believe that Cigna has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by sending an email to ACAGrievance Cigna.
You can also file a civil rights complaint with the U. For current Cigna customers, call the number on the back of your ID card. Otherwise, call 1. Si no lo es, llame al 1. Para sa mga kasalukuyang customer ng Cigna, tawagan ang numero sa likuran ng iyong ID card.
O kaya, tumawag sa 1. Sinon, rele nimewo 1. Wszystkie inne osoby prosimy o skorzystanie z numeru 1 TTY: wybierz Per i clienti Cigna attuali, chiamare il numero sul retro della tessera di identificazione. In caso contrario, chiamare il numero 1. Andernfalls rufen Sie 1. Is your doctor or hospital in the Cigna network? Step 4 Select one of the plans offered by your employer during open enrollment. You can also refine your search results by distance, years in practice, specialty, languages spoken and more.
Search first. Then choose Cigna. There are so many things to love about Cigna. Our directory search is just the beginning. On myCigna, you can estimate your health care costs, manage and track claims, learn how to live a healthier life and more. Health care professionals and facilities that participate in the Cigna network are independent practitioners solely responsible for the treatment provided to their patients.
They are not agents of Cigna. All products or services are provided by or through such operating subsidiaries and not by Cigna Corporation. Louis, Inc. Your prescription drug list This drug list includes the most commonly prescribed medications covered by your plan as of January 1, This drug list is not a complete list of covered medications, and not all of the medications listed here may be covered by your specific plan.
You should log into myCigna. Generic medications are lowercase Medications that require approval for coverage or have limits will have an abbreviation listed next to them.
Typically, the higher the tier, the greater the cost of the medication. Abbreviations next to medications Some medications on your drug list have special requirements before they may be covered by your plan.
These medications will have an abbreviation next to them in the drug list. PA Prior Authorization — Your doctor has to provide Cigna with information about why you need to use this medication. The medication will only be covered if your doctor requests and receives approval from Cigna. Step Therapy encourages the use of lower-cost, clinically appropriate medications to treat your condition. These are typically generics or preferred brands. You have to try these medications first before your plan covers higher-cost brands.
For example, 30mg per day for 30 days. Your plan will only cover a larger amount if your doctor requests and receives approval from Cigna. Brand name medications are capitalized In this drug list, brand name medications are capitalized and generic medications begin with a lowercase letter. Specialty medications are marked with an asterisk Specialty medications are used to treat complex conditions like multiple sclerosis, hepatitis C and rheumatoid arthritis. Log into myCigna. No cost-share preventive medications are marked with a plus sign Health care reform under the Patient Protection and Affordable Care Act PPACA requires that most plans cover certain categories of medications and other products as preventive care services.
Plan exclusions Some medications shown in this drug list may not be covered by your specific plan. For example, medications used for weight loss or to treat infertility may not be covered. How to find your medication on the drug list Look for your condition in the alphabetical list below.
Then go to that page to see the list of covered medications available to treat the condition. Alphagan P 0. Acuvail Alphagan P 0.
You should think about switching to a covered alternative. Anucort-HC Hemmorex-HC hydrocortisone suppository Apriso balsalazide Lialda Pentasa sulfasalazine sulfasalazine DR chlordiazepoxide-clidinium alosetron dronabinol esomeprazole lansoprazole-amoxicillinclarithromycin pak omeprazole famotidine Generic prescription PPIs e. Generic products e.
Prescription drug list FAQs We want to make sure you understand your prescription drug coverage so you can get the most from your pharmacy benefit. Below are answers to some of the most commonly asked questions about the Cigna Prescription Drug List. How do you decide what medications are covered? Every medication available on the drug list has been approved by the FDA. The business team reviews their findings and other factors when deciding the placement of the medication on the drug list.
Our goal is to provide access to coverage for safe, clinically effective and low-cost medications. Cigna regularly reviews and updates the prescription drug list. We make updates to the drug list for many reasons, like when new generics become available, medications are no longer available or when medication prices change.
For example, the price of a brand name medication may increase much more than other medications that treat the same condition. These changes may include What medications are covered under the health care reform law? This typically happens twice per year on January 1st and July 1st. When a medication changes tiers or is no longer covered, you may have to pay a different amount to fill that medication.
Some high-cost medications have clinically appropriate alternatives. Meaning, they work the same or similar to another covered prescription medication or over-the-counter available without a prescription alternative.
To help lower your overall health care costs, these high-cost medications are not covered. Are medications newly approved by the FDA covered on my drug list? Newly approved medications may not be covered on your drug list for the first six months after they receive FDA approval. These include, but are not limited to, medications, medical supplies or devices covered under standard pharmacy benefit plans.
We review all newly Prescription drug list FAQs cont Call us at You can also go to cigna. Use the Drug Cost tool on myCigna. Can I fill my prescriptions by mail? If you take a medication every day to treat an ongoing health condition, you can order up to a day supply through Cigna Home Delivery Pharmacy. SM 3 To get started, call us at You may be able to save money by switching to a lower-cost medication or by filling a day supply, if your plan allows.
Talk with your doctor to see if a lower-cost medication, or day supply, may work for you. Use the online tools and resources on myCigna. You can view your drug list or search for a specific medication, use Drug Cost tool to estimate how much your medications may cost, find a pharmacy in your network and review your pharmacy claims and payment history. The FDA requires generic medications to have the same quality and performance as brand name medications. A generic medication is the same as a brand name medication in dosage form, active ingredient, strength, route of administration, quality, performance characteristics and intended use.
How can I get help with my specialty medication? They offer condition-specific education on medication therapy and side effects, help manage the approval process and offer financial assistance programs if you need help paying for your specialty medication.
Exclusions and limitations Health benefit plans vary, but in general to be eligible for coverage a drug must be approved by the Food and Drug Administration FDA , prescribed by a health care professional, purchased from a licensed pharmacy and be medically necessary.
If your plan provides coverage for certain preventive prescription drugs with no cost-share, you may be required to use an in-network pharmacy to fill the prescription. Certain drugs may require prior authorization, or be subject to step therapy, quantity limits or other utilization management requirements. Plans generally do not provide coverage for the following under the pharmacy benefit, except as required by state or federal law, or by the terms of your specific plan Cigna reserves the right to make changes to the Drug List without notice.
Your plan may cover additional medications; please refer to your enrollment materials for details. Cigna does not take responsibility for any medication decisions made by the doctor or pharmacist. Cigna may receive payments from manufacturers of certain preferred brand medications, and in limited instances, certain non-preferred brand medications, that may or may not be shared with your plan depending on its arrangement with Cigna. State laws in Texas and Louisiana require your plan to cover your medications at your current benefit level until your plan renews.
To find out if these state laws apply to your plan, please call Customer Service using the number on the back of your ID card. Please check your plan materials for more information on what pharmacies are covered under your plan. The downloading and use of the myCigna app is subject to the terms and conditions of the app and the online stores from which it is downloaded. If there are any differences between the information provided here and the plan documents, the information in the plan documents takes complete precedence.
Specialty medications are used to treat complex conditions like multiple sclerosis, hepatitis C and rheumatoid arthritis. This drug list includes the most commonly prescribed specialty medications covered by your plan as of January 1, This drug list is not a complete list of covered specialty medications, and not all of the medications listed here may be covered by your specific plan.
This list is also regularly updated. Our therapy management teams, made up of health advocates with nursing backgrounds and pharmacists, are specially trained to deliver the best experience possible by offering:. Call us at Depending on your plan, you may be able to fill your prescription one time at any in-network retail pharmacy before you have to use Cigna Specialty Pharmacy Services. Refer to your plan materials or myCigna. Health benefit plans vary, but in general to be eligible for coverage a drug must be approved by the Food and Drug Administration FDA , prescribed by a health care professional, purchased from a licensed pharmacy and medically necessary.
If your plan provides coverage for certain prescription drugs with no cost-share, you may be required to use an in-network pharmacy to fill the prescription. Certain features described in this document may not be applicable to your specific health plan, and plan features may vary by location and plan type. Learn what your Cigna plan offers Cigna health plans offer so much more than coverage for basic medical needs. We offer the programs, tools, services and resources you need to help you better manage your health — and health spending.
Here are some important highlights to help get the most out of your Cigna health plan starting today — and in the days and months to come. At Cigna, we want to partner with you and support you in your health journey. Life can be busy and complicated. The myCigna Mobile App helps you personalize, organize and access your important plan information on your phone and tablet.
The app is also available in Spanish. Use the myCigna Mobile App to login in anytime, anywhere to:. If you have already registered for myCigna. Log in to myCigna. Click on the health assessment tile 4. Get started If you have never registered for myCigna:. Apple and the Apple logo are trademarks of Apple Inc. App Store is a service mark of Apple Inc. Amazon, Kindle, Fire and all related logos are trademarks of Amazon. Blackberry and Blackberry World are trademarks or registered trademarks of BlackBerry Limited, the exclusive rights to which are expressly reserved.
Cigna is not affiliated with, endorsed, sponsored, or otherwise authorized by BlackBerry Limited. And you can take myCigna with you wherever you go. You will need your username and password each time you visit the site.
At Cigna, we focus on helping to keep you well. We encourage you to talk with a doctor who is part of the Cigna network to determine what tests or health screenings are right for you. Covered preventive care services may include, but are not limited to The name of your Cigna health plan and the health care professional networks you can access for care Addresses where you or you doctor will send your medical and pharmacy claims.
Working together to improve your health Cigna has many services to help you with your personal health needs, including the following:. Care management programs give you access to a Cigna case manager, trained as a nurse, who works closely with your doctor and contacts you on a regular basis to check on your progress.
You can ask for help and guidance with conditions and illnesses such as cancer, end-stage renal disease, neonatal care and pain management. Screenings for high blood pressure and cholesterol Testing for diabetes and colon cancer Clinical breast exams and mammograms Pap tests. View our health care professional directory to find an in-network doctor or facility near you on myCigna. My Health Assistant Cigna offers an online, personal coaching service with programs that can jump start your goals and help you start feeling healthier and happier.
My Health Assistant on myCigna. Choose from one of the following programs to help you establish personal goals and track your progress:. Access to care Right Service. Right Place. Cigna wants to help you find the right services for your health care needs. If you need immediate medical attention, your first thought may be to go the emergency room.
But an urgent care center may be a more convenient, less expensive alternative if you have one in your area. An urgent care center can treat you for things like minor cuts, burns and sprains, fever and flu symptoms, joint or lower back pain and urinary tract infections. If you have a serious or life-threatening condition, always dial or visit the nearest hospital.
Most drugs fall into one of three categories Copay A preset amount you pay for your covered health care services. The plan pays the rest. Generic Medications: Generic medications have the same active ingredients, dosage and strength as their brand name counterparts.
You will usually pay less for generic medications. Coinsurance Your share of the cost of your covered health care costs after deductibles have been met. Your plan pays the rest of covered charges. If you go out-of-network for care, your expenses may be greater than the coinsurance amount.
Preferred Brand Medications: Preferred brand medications will usually cost more than a generic, but may cost less than a non-preferred brand. You will usually pay more for non-preferred medications.
In-network Health care professionals, pharmacies and facilities that have contracts with Cigna to deliver services at a negotiated rate discount. You will typically have lower out-of-pocket costs for services you received in-network.
Cigna also gives you access to more than 68, pharmacies in our network. Using an out-ofnetwork health care professional or facility will typically cost you more. From health care questions to coverage concerns, whenever you need us, call 1. Also known as your PCP, this is your personal health care provider who coordinates all of your medical care, from routine physicals to recommending specialists. He or she gets to know you, your medical history and your personal preferences.
And that can be very valuable. Precertification is getting approval from the health plan before receiving services, such as for routine hospital stays or outpatient procedures. In precertification, Cigna or its agent reviews medical criteria to determine coverage under your plan. You can order an ID card, update insurance information and check claim status. Access our health information line where Cigna staff, trained as nurses, can help you find answers to your health questions, and help you decide where and when to seek medical attention.
If you want to speak with someone in Spanish, we have bilingual representatives. We also have services that can translate other languages. The downloading and use of the myCigna Mobile App is subject to the terms and conditions of the App and the online stores from which it is downloaded.
Actual myCigna and App features available may vary depending on your plan. The listing of a health care professional or facility in the online directories does not guarantee that the services rendered by that professional or facility are covered under your specific medical plan. Check your benefit summary and plan documents, or call the number listed on your ID card, for information about the services covered under your plan benefits.
Covered preventive care services may vary depending on your age, gender and medical history. Plans may vary and some preventive services may not be covered under your plan. For example, immunizations for travel are generally not covered. For the coverage terms of your specific medical plan, see your plan materials. Pharmacy availability and network will vary based on your plan. All group health insurance policies and health benefit plans have exclusions and limitations.
This information is intended to give you some highlights about your plan. If there are any differences between the information shown here and the plan documents, the information in the plan documents takes precedence. The health care professionals and facilities that participate in the Cigna network are independent contractors solely responsible for the treatment provided to their patients. Choice is good. More choice is even better.
Cigna Telehealth Connection lets you get the care you need — including most prescriptions — for a wide range of minor conditions. Now you can connect with a board-certified doctor via secure video chat or phone, without leaving your home or office. When, where and how it works best for you! Choose when: Day or night, weekdays, weekends and holidays. Choose where: Home, work or on the go. Choose how: Phone or video chat. The cost savings are clear. Televisits with AmWell and MDLIVE can be a cost-effective alternative to a convenience care clinic or urgent care center, and cost less than going to the emergency room.
And the cost of a phone or online visit is the same or less than with your primary care provider. Remember, your telehealth services are only available for minor, non-life threatening conditions.
In an emergency, dial or go to the nearest hospital. For covered services related to mental health and substance abuse, you have access to the Cigna Behavioral Health network of providers. Choose with confidence. See vendor sites for details. Providers are solely responsible for any treatment provided. Not all providers have video chat capabilities. Video chat is not available in all areas. Telehealth services may not be available to all plan types. In general, to be covered by your plan, services must be medically necessary and used for the diagnosis or treatment of a covered condition.
Not all prescription drugs are covered. All group health insurance policies and health benefit plans contain exclusions and limitations. What is Continuity of Care? Continuity of Care allows you to receive services at in-network coverage levels for specified medical conditions for a defined period of time when your health care professional leaves the Cigna network and there are solid clinical reasons preventing immediate transfer of care to another health care professional. This includes any precertification requirements.
All other conditions must be cared for by an in-network health care professional for you to receive in-network coverage levels. Nor does it constitute precertification of medical services to be provided.
Depending on the actual request, a medical necessity determination and formal precertification may still be required for a service to be covered. Newly diagnosed or relapsed cancer in the midst of chemotherapy, radiation therapy or reconstruction. Recent major surgeries still in the follow-up period generally six to eight weeks. Acute conditions in active treatment such as heart attacks, strokes or unstable chronic conditions, etc.
Hospital confinement on the plan effective date only for those plans that do not have extension-of-coverage provisions. Stable chronic conditions such as diabetes, arthritis, allergies, asthma, hypertension and glaucoma.
Acute minor illnesses such as colds, sore throats and ear infections. Elective scheduled surgeries such as removal of lesions, bunionectomy, hernia repair and hysterectomy. What time frame is allowed for transitioning to a new participating health care professional?
If Cigna determines that transitioning to a participating health care professional is not recommended or safe for the conditions that qualify, services by the approved non-participating health care professional will be authorized for a specified period of time usually 30 days or until care has been completed or transitioned to a participating health care professional, whichever comes first.
After receiving your request, Cigna will review and evaluate the information provided and will send you a letter informing you whether your request was approved or denied. What is Transition of Care?
Transition of Care coverage allows you to continue to receive services for specified medical conditions for a defined period of time with health care professionals who do not participate in the Cigna network until the safe transfer of care to a participating doctor or facility can be arranged. You must apply for Transition of Care at enrollment, or change in Cigna medical plan, but no later than 60 days after the effective date of your coverage.
Photocopies are acceptable. Attach additional information if needed. Is the patient pregnant and in the second or third trimester of pregnancy? Please complete the health care professional information request below. Group practice name Health care professional name.
Health care professional specialty Health care professional address Hospital where health care professional practices. Treatment being received and expected duration Please list any other continuing care needs that may qualify for Transition of Care or Continuity of Care coverage. If these care needs are not associated with the condition for which you are applying for Transition of Care or Continuity of Care coverage, you need to complete a separate Transition of Care or Continuity of Care form.
I understand I am entitled to a copy of this authorization form. Signature of patient, parent or guardian. Review for organ transplant requests may take longer. Additional forms are available on Cigna. Please make certain that all questions are completely answered. To help ensure a timely review of your request, please return the form as soon as possible.
In 9, include information about your current or proposed treatment plan and the length of time your treatment is expected to continue. If surgery has been planned, state the type and the proposed date of the surgery. In 12, briefly state the health condition, when it began and the health care professional who is currently involved.
Also include how often you see this health care professional. Please be as specific as possible. In 13, if you answered Yes for customers receiving mental health services: 1. If you are receiving outpatient mental health services, you should do one of the following.
The first few sections of the form apply to the employee. The address is on the back of your Cigna ID card, or call If you are receiving inpatient, residential, partial hospitalization or intensive outpatient services, regardless of your plan type, call or have your health care professional call the customer service number on the back of your Cigna ID card, or call Review for Organ Transplant requests may take longer.
All models are used for illustrative purposes only. How the plan works How do I find a provider? To find a provider, go to carefirst.
Be sure to ask your provider if he or she participates with the Davis Vision network before you receive care. How do I receive care from a network provider? Simply call your provider and schedule an appointment. Then go to the provider to receive your service. There are no claim forms to file. What if I go out-of-network? Staying in-network gives you the best benefit, but BlueVision Plus does offer an out-of-network allowance schedule as well.
In this case, you may see any provider you wish, but you will be responsible for all payments up-front. You will also be responsible for filing the claim with Davis Vision for reimbursement and paying any balances over the allowed benefit to the non-participating provider. You can find the claim form by going to carefirst.
Can I get contacts and eyeglasses in the same benefit period? With BlueVision Plus, the benefit covers one pair of eyeglasses or a supply of contact lenses per benefit period. Mail order replacement contact lenses DavisVisionContacts. This website offers a wide array of contact lenses, easy, convenient purchasing online and quick shipping direct to your door. This portion of the Plan is not an insurance product. Exclusions The following services are excluded from coverage: 1.
Medical care or surgery. Covered services related to medical conditions of the eye may be covered under the Evidence of Coverage. Prescription drugs obtained and self-administered by the Member for outpatient use unless the prescription drug is specifically covered under the Evidence of Coverage or a rider or endorsement purchased by your Group and attached to the Evidence of Coverage.
Orthoptics, vision training and low vision aids. Replacement, within the same benefit period of frames, lenses or contact lenses that were lost. Non-prescription glasses, sunglasses or contact lenses. Vision Care services for cosmetic use. CareFirst of Maryland, Inc. You get benefits for a wide range of covered services — both in and out of the network.
The goal is to deliver affordable protection for a healthier smile and a healthier you. Negotiated fees are subject to change. Certain plan benefits are based on a percentage of the negotiated fee. This is the amount that participating dentists have agreed to accept as payment in full. Savings from enrolling in a dental benefits plan will depend on various factors, including the cost of the plan, how often participants visit the dentist and the cost of services rendered. All dental procedures performed in connection with orthodontic treatment are payable as Orthodontia.
Payments are on a repetitive basis. The service categories and plan limitations shown in this document represent an overview of your plan benefits, but are not a complete description of the plan. Before making any purchase or enrollment decision you should review the certificate of insurance which is available through MetLife or your employer.
In the event of a conflict between this overview and your certificate of insurance, your certificate of insurance governs. Like most group dental insurance policies, MetLife group policies contain certain exclusions, limitations and waiting periods and terms for keeping them in force. The certificate of insurance sets forth all plan terms and provisions, including all exclusions and limitations. If you and your dentist have agreed on a treatment that is more costly than the treatment upon which the plan benefit is based, you will be responsible for any additional payment responsibility.
To avoid any misunderstandings, we suggest you discuss treatment options with your dentist before services are rendered, and obtain a pretreatment estimate of benefits prior to receiving certain high cost services such as crowns, bridges or dentures. You and your dentist will each receive an Explanation of Benefits.
Actual payments may vary from the pretreatment estimate depending upon annual maximums, plan frequency limits, deductibles and other limits applicable at time of payment. Exclusions We will not pay Dental Insurance benefits for charges incurred for: 1. Services which are not Dentally Necessary, those which do not meet generally accepted standards of care for treating the particular dental condition, or which We deem experimental in nature.
Services for which You would not be required to pay in the absence of Dental Insurance. Services or supplies received by You or Your Dependent before the Dental Insurance starts for that person.
Services which are primarily cosmetic For residents of Texas, see notice page section in your certificate. Services or appliances which restore or alter occlusion or vertical dimension.
Restoration of tooth structure damaged by attrition, abrasion or erosion. Restorations or appliances used for the purpose of periodontal splinting. Counseling or instruction about oral hygiene, plaque control, nutrition and tobacco. Personal supplies or devices including, but not limited to: water piks, toothbrushes, or dental floss. Decoration, personalization or inscription of any tooth, device, appliance, crown or other dental work.
Missed appointments. Services covered under other coverage provided by the Employer. Temporary or provisional restorations. Temporary or provisional appliances. Prescription drugs. Services for which the submitted documentation indicates a poor prognosis.
Dental services arising out of accidental injury to the teeth and supporting structures, except for injuries to the teeth due to chewing or biting of food.
Caries susceptibility tests. Initial installation of a fixed and permanent Denture to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth.
Other fixed Denture prosthetic services not described elsewhere in this certificate. Precision attachments. Adjustment of a Denture 26 Appliances or treatment for bruxism grinding teeth , including but not limited to occlusal guards and night guards.
This exclusion does not apply to residents of Minnesota. Repair or replacement of an orthodontic device. Duplicate prosthetic devices or appliances. Replacement of a lost or stolen appliance, Cast Restoration, or Denture. Intra and extraoral photographic images. How do I find a participating dentist? You can access a list of participating dentists with directions and mapping capabilities online at www.
Please Note: Be sure to verify provider participation when you make your appointment. May I choose a non-participating dentist?
You are always free to select the dentist of your choice. Please note: any plan deductibles must be met before benefits are paid. Can my dentist apply for participation in network? If your current dentist does not participate in the MetLife network and you would like to encourage him or her to apply, tell your dentist to visit www. The website and phone number are designed for use by dental professionals only.
How are claims processed? Dentists may submit your claims for you, which means you have little or no paperwork. You can track your claims online and even receive e-mail alerts when a claim has been processed. If you need a claim form, you can find one online at www. Can I find out what my out-of-pocket expenses will be before receiving a service? With pre-treatment estimates, you never have to wonder what your out-of-pocket expense will be.
To receive a benefit estimate, simply have your dentist submit a request for a pre-treatment estimate online at www. You and your dentist will receive a benefit estimate online or by fax for most procedures while you are still in the office so you can discuss treatment and payment options and have the procedure scheduled on the spot.
Actual payments may vary depending upon plan maximums, deductibles, frequency limits and other conditions at time of payment. Do I need an ID card? No, you do not need to present an ID card to confirm that you are eligible. Your dentist can easily verify information about your coverage through a toll-free automated Computer Voice Response system.
Do my dependents have to visit the same dentist that I select? No, you and your dependents each have the freedom to choose any dentist. If I do not enroll during my initial enrollment period can I still purchase Dental Insurance at a later date? Yes, eligible employees who do not elect coverage during their day application period may still elect coverage later. Please consult your Benefits Administrator or your certificate for this plan information.
Am I eligible for all benefits the first day of coverage? Your plan may include benefit waiting periods. Please refer to the certificate of insurance or your Benefits Administrator for details about the services that are subject to the waiting periods and the length of time they apply. How can I learn about what dentists in my area charge for different procedures?
You can use the tool to look up average in- and out-of-network fees for dental services in your area. Just log in at www. Network fee information is supplied to VerifPoint by MetLife and is not available for providers who participate with MetLife through a third-party.
Out-of-network fee information is provided by VerifPoint. This tool does not provide the payment information used by MetLife when processing your claims. Prior to receiving services, pretreatment estimates through your dentist will provide the most accurate fee and payment information Can MetLife help me find a dentist outside of the U. Coverage will be considered under your out-of-network2 benefits. Please remember to hold on to all receipts to submit a dental claim.
AXA Assistance and Virginia Surety are not affiliated with MetLife, and the services and benefits they provide are separate and apart from the insurance provided by MetLife. Referral services are not available in all locations. You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card, if any, or For more help call the CA Dept. To receive a copy of the attached MetLife document translated into Spanish or Chinese, please mark the box by the requested language statement below, and mail the document with this form to: Metropolitan Life Insurance Company PO Box Lexington, KY Please indicate to whom and where the translated document is to be sent.
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Maaari kang kumuha ng tagasalin para basahin sa iyo ang mga dokumento sa wikang Tagalog. Para ikaw ay matulungan, tawagan kami sa numerong nakalista sa iyong ID card, kung mayroon man, o sa numerong
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