March 20, 2010

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CIGNA – Open Access 3000 – TENNESSEE

A comparison of the Open Access 3000 offered by CIGNA is detailed out below for both Network and Non-Network coverage.

  Network Non-Network
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Network See Provider See Provider
Application Open Access 3000 Application Open Access 3000 Application
Brochure Open Access 3000 Brochure Open Access 3000 Brochure
Copay Primary Care Physician: $30 copay, Specialist: $40 copay Primary Care Physician: CIGNA pays 50% after deductible, Specialist: CIGNA pays 50% after deductible
Office Visit Primary Care Physician: $30 copay, Specialist: $40 copay Primary Care Physician: CIGNA pays 50% after deductible, Specialist: CIGNA pays 50% after deductible
Deductible Individual: $3,000, Family: $6,000 Individual: $6,000, Family: $12,000
Coinsurance CIGNA pays 70% of eligible charges CIGNA pays 50% of eligible charges
Coinsurance Limit N/A N/A
Out-of-Pocket Maximum Individual: $4,000, Family: $8,000 Individual: $8,000, Family: $16,000
Lifetime Maximum $6,000,000 per member $6,000,000 per member
Prescription Drugs Retail Pharmacy (30-day supply):
  • Brand Name Prescription Drug Deductible: $500 per member
  • Generic: You pay $10
  • Brand Name: You pay $35
  • Non Preferred Brand Name: You pay $60
  • Self Injectables: You pay 30%
Mail Order Pharmacy (90-day supply):
  • Generic: You pay $25
  • Brand Name: You pay $85
  • Non Preferred Brand Name: You pay $150
  • Self Injectables: You pay 30%
 Retail Pharmacy (30-day supply):
  • Brand Name Prescription Drug Deductible: $500 per member
  • Generic: CIGNA pays 50%
  • Brand Name: CIGNA pays 50%
  • Non Preferred Brand Name: CIGNA pays 50%
  • Self Injectables: CIGNA pays 50%
Mail Order Pharmacy (90-day supply):
  • Generic: Not covered
  • Brand Name: Not covered
  • Non Preferred Brand Name: Not covered
  • Self Injectables: Not covered
Emergency Room
  • Hospital Emergency Room (including radiology, pathology and ER physician and ancillary charges): CIGNA pays 70% after deductible ($100 additional deductible, waived if admitted)
  • Ambulance (Emergency transport only): CIGNA pays 70% after deductible
    		•
  • Hospital Emergency Room (including radiology, pathology and ER physician and ancillary charges): CIGNA pays 50% after deductible ($100 additional deductible, waived if admitted)
  • Ambulance (Emergency transport only): CIGNA pays 50% after deductible
    		•
    Adult Preventative Care Adult Preventive Care (age 7 and older):
    • Mammogram, Pap Smear, PSA: $30/$40 copay
    • All other routine services (calendar year maximum of $250 per member, per year, in and out of network combined): $30/$40 copay, then CIGNA pays 100% up to $250, deductible waived
    		 Child Preventive Care (through age 6):
    • Office Visit: CIGNA pays 50% after deductible
    • Immunizations, x-ray and laboratory: CIGNA pays 50%, deductible waived
    • All other routine services: CIGNA pays 50%
    Child Preventative Care Child Preventive Care (through age 6):
    • Office Visit: $30/$40 copay
    • Immunizations, x-ray and laboratory: CIGNA pays 70%, deductible waived
    • All other routine services: $30/$40 copay, then CIGNA pays 70%, deductible waived
    		 Child Preventive Care (through age 6):
    • Office Visit: CIGNA pays 50% after deductible
    • Immunizations, x-ray and laboratory: CIGNA pays 50%, deductible waived
    • All other routine services: CIGNA pays 50%
    Lab / X-Ray CIGNA pays 70% after deductible CIGNA pays 50% after deductible
    Maternity Not Covered Not Covered
    Physical Therapy Short Term Rehabilitative Therapy (including Spinal Manipulation; Physical Therapy, Occupational Therapy and Speech Therapy): CIGNA pays 70% after deductible (Calendar year maximum 24 visits, combined services, in and out of network combined) Short Term Rehabilitative Therapy (including Spinal Manipulation; Physical Therapy, Occupational Therapy and Speech Therapy): CIGNA pays 50% after deductible (Calendar year maximum 24 visits, combined services, in and out of network combined)
    Skilled Nursing Skilled Nursing Facility, Rehabilitation Hospital and Subacute Facilities: CIGNA pays 70% after deductible (Calendar year maximum 30 days, combined services, in and out of network combined) Skilled Nursing Facility, Rehabilitation Hospital and Subacute Facilities: CIGNA pays 50% after deductible (Calendar year maximum 30 days, combined services, in and out of network combined)
    Home Health Care CIGNA pays 70% after deductible (Calendar year maximum 30 days, in and out of network combined) CIGNA pays 50% after deductible (Calendar year maximum 30 days, in and out of network combined)
    Mental Health
  • Inpatient: CIGNA pays 70% after deductible (Calendar year maximum 30 days, in and out of network combined)
  • Outpatient: CIGNA pays 70% after deductible (Calendar year maximum 20 days, in and out of network combined)
    		•
  • Inpatient: CIGNA pays 50% after deductible (Calendar year maximum 30 days, in and out of network combined)
  • Outpatient: CIGNA pays 50% after deductible (Calendar year maximum 20 days, in and out of network combined)
    		•
    Hospital Care Inpatient Hospital Facility Services:
    • Semi Private Room and Board all In-Hospital Care Services (inpatient room and board, pharmacy, x-ray and laboratory, operating room, etc.): CIGNA pays 70% after deductible
    		 Inpatient Hospital Facility Services:
    • Semi Private Room and Board all In-Hospital Care Services (inpatient room and board, pharmacy, x-ray and laboratory, operating room, etc.): CIGNA pays 50% after deductible
    Optional Benefits N/A N/A