CT Mycigna Health Savings 6100

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Cigna Health and Life Insurance Company: CT myCigna Health Savings 6100 Coverage Period: 1/1/15-12/31/15 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Family | Plan Type: OAP

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.cigna.com/individuals-families/connecticut or by calling 1-800-Cigna24.

Important Questions Answers Why this Matters: For in-network providers $6,100 person/ $12,200 family You must pay all the costs up to the deductible amount before this plan begins to For out of-network providers $12,500 person/ pay for covered services you use. Check your policy or plan document to see when What is the overall $25,000 family the deductible starts over (usually, but not always, January 1st). See the chart deductible? Does not apply to in-network preventive care, starting on page 2 for how much you pay for covered services after you meet the in-network dental care for children and eye deductible . exam for children. Are there other You don’t have to meet deductibles for specific services, but see the chart starting deductibles for specific No. on page 2 for other costs for services this plan covers. services? Yes, For in-network providers $6,350 person/ Is there an out–of– $12,700 family The out-of-pocket limit is the most you could pay during a coverage period (usually pocket limit on my one year) for your share of the cost of covered services. This limit helps you plan for For out-of-network providers $25,000 person/ expenses? health care expenses. $50,000 family Premium, balanced-billed charges, penalties What is not included in for failure to obtain pre-authorization for Even though you pay these expenses, they don’t count toward the out-of-pocket the out–of–pocket services, and health care this plan doesn’t limit . limit? cover Is there an overall The chart starting on page 2 describes any limits on what the plan will pay for specific annual limit on what No. covered services, such as office visits the plan pays? If you use an in-network doctor or other health care provider , this plan will pay some Yes. For a list of participating providers, see or all of the costs of covered services. Be aware, your in-network doctor or hospital Does this plan use a www.cigna.com/ifp-providers or call may use an out-of-network provider for some services. Plans use the term in- network of providers? 1-800-Cigna24 network, preferred , or participating for providers in their network . See the chart starting on page 2 for how this plan pays different kinds of providers

Questions: Call 1-800-Cigna24 or visit us at www.cigna.com/individuals-families/connecticut If you aren’t clear about any of the bolded terms used in this form, see the Glossary. 1 of 9 You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy. Cigna Health and Life Insurance Company: CT myCigna Health Savings 6100 Coverage Period: 1/1/15-12/31/15 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Family | Plan Type: OAP

Do I need a referral to No. You don’t need a referral to see a You can see the specialist you choose without permission from this plan. see a specialist? specialist

Are there services this Some of the services this plan doesn’t cover are listed on page 6. See your policy or Yes. plan doesn’t cover? plan document for additional information about excluded services .

• Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. • Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible . • The amount the plan pays for covered services is based on the allowed amount . If an out-of-network provider charges more than the allowed amount , you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing .) • This plan may encourage you to use participating _ providers by charging you lower deductibles , copayments and coinsurance amounts.

Your Cost I f Your Cost I f Common Services You May Need You Use an You Use an Limitations & Exceptions Medical Event In-network Out-of-network Provider Provider Primary care visit to treat an injury or illness No charge 50% co-insurance ------None------If you visit a health Specialist visit No charge 50% co-insurance ------None------care provider’s office or clinic Other practitioner office visit No charge 50% co-insurance ------None------Preventive care/screening/immunization No charge 50% co-insurance ------None------Diagnostic test (x-ray, blood work) No charge 50% co-insurance ------None------If you have a test Pre -authorization required, call 1 -800 - Imaging (CT/PET scans, MRIs) No charge 50% co-insurance Cigna24. Out-of-network cost share increases if no pre-authorization.

Questions: Call 1-800-Cigna24 or visit us at www.cigna.com/individuals-families/connecticut If you aren’t clear about any of the bolded terms used in this form, see the Glossary. 2 of 9 You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy. Cigna Health and Life Insurance Company: CT myCigna Health Savings 6100 Coverage Period: 1/1/15-12/31/15 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Family | Plan Type: OAP

Your Cost I f Your Cost I f Common Services You May Need You Use an You Use an Limitations & Exceptions Medical Event In-network Out-of-network Provider Provider 50% co -insurance No charge (retail) / Coverage is limited to a 30-day supply (retail)/50% co- Preferred generic drugs No charge (home (retail) and up to 90-day supply (home insurance (home delivery) delivery) delivery) 50% co -insurance No charge (retail) / Coverage is limited to a 30-day supply (retail)/50% co- Non-preferred generic drugs No charge (home (retail) and up to 90-day supply (home If you need drugs to insurance (home delivery) delivery) treat your illness or delivery) condition 50% co -insurance No charge (retail) / Coverage is limited to a 30-day supply (retail)/50% co- Preferred brand drugs No charge (home (retail) and up to a 90-day supply (home More information about insurance (home delivery) delivery). prescription drug delivery) coverage is available 50% co -insurance 50% co -insurance Coverage is limited to a 30-day supply www.cigna.com/ifp- (retail) / 50% co- (retail) / 50% co- Non-preferred brand drugs (retail) and up to a 90-day supply (home drug-list insurance (home insurance (home delivery) delivery) delivery) Cover age is limited to a 30-day supply 50% co-insurance No charge (retail) / (retail) and up to a 30-day supply (home (retail)/50% co- Specialty drugs No charge (home delivery). Pre-authorization required, call insurance (home delivery) 1-800-Cigna24. Cost share increases if delivery) no pre-authorization. Facility fee (e.g., ambulatory surgery center) No charge 50% co-insurance ------None------If you have outpatient Pre -authorization required, call 1 -800 - surgery Physician/surgeon fees No charge 50% co-insurance Cigna24. Out-of-network cost share increases if no pre-authorization. Emergency room services No charge No charge ------None------If you need immediate Emergency medical transportation No charge No charge ------None------medical attention Urgent care No charge No charge ------None------

Questions: Call 1-800-Cigna24 or visit us at www.cigna.com/individuals-families/connecticut If you aren’t clear about any of the bolded terms used in this form, see the Glossary. 3 of 9 You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy. Cigna Health and Life Insurance Company: CT myCigna Health Savings 6100 Coverage Period: 1/1/15-12/31/15 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Family | Plan Type: OAP

Your Cost I f Your Cost I f Common Services You May Need You Use an You Use an Limitations & Exceptions Medical Event In-network Out-of-network Provider Provider Pre -authorization required, call 1 -800 - If you have a hospital Facility fee (e.g., hospital room) No charge 50% co-insurance Cigna24. Out-of-network cost share stay increases if no pre-authorization. Physician/surgeon fee No charge 50% co-insurance ------None------Mental/Behavioral health outpatient services No charge 50% co-insurance ------None------Pre -authorization required, call 1 -800 - If you have mental Mental/Behavioral health inpatient services No charge 50% co-insurance Cigna24. Out-of-network cost share health, behavioral increases if no pre-authorization. health, or substance Substance use disorder outpatient services No charge 50% co-insurance ------None------abuse needs Pre -authorization required, call 1 -800 - Substance use disorder inpatient services No charge 50% co-insurance Cigna24. Out-of-network cost share increases if no pre-authorization. All prenatal and first postpartum Prenatal and postnatal care No charge 50% co-insurance consultations If you are pregnant Pre -authorization required, call 1 -800 - Delivery and all inpatient services No charge 50% co-insurance Cigna24. Out-of-network cost share increases if no pre-authorization.

Questions: Call 1-800-Cigna24 or visit us at www.cigna.com/individuals-families/connecticut If you aren’t clear about any of the bolded terms used in this form, see the Glossary. 4 of 9 You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy. Cigna Health and Life Insurance Company: CT myCigna Health Savings 6100 Coverage Period: 1/1/15-12/31/15 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Family | Plan Type: OAP

Your Cost I f Your Cost I f Common Services You May Need You Use an You Use an Limitations & Exceptions Medical Event In-network Out-of-network Provider Provider Coverage is limited to 100 days annual max. Pre-authorization required, call 1- Home health care No charge 25% co-insurance 800-Cigna24. Out-of-network cost share increases if no pre-authorization. Coverage of physical , occupational and Rehabilitation services No charge 50% co-insurance speech therapy is limited to 40 visits, chiropractic 20 visits annual max If you need help Coverage is limited to 40 visits annual Habilitation services No charge 50% co-insurance recovering or have max other special health Coverage is limited to 90 days annual needs max. Pre-authorization required, call 1- Skilled nursing care No charge 50% co-insurance 800-Cigna24. Out-of-network cost share increases if no pre-authorization. Durable medical equipment No charge 50% co-insurance ------None------Pre -authorization required, call 1 -800 - Hospice service No charge 50% co-insurance Cigna24. Out-of-network cost share increases if no pre-authorization. Eye exam No charge Not covered Coverage is limited to 1 exam per year If your child needs Coverage is limited to 1 pair of glasses Glasses No charge Not covered dental or eye care per year Dental check -up No charge No charge ------None ------

Questions: Call 1-800-Cigna24 or visit us at www.cigna.com/individuals-families/connecticut If you aren’t clear about any of the bolded terms used in this form, see the Glossary. 5 of 9 You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy. Cigna Health and Life Insurance Company: CT myCigna Health Savings 6100 Coverage Period: 1/1/15-12/31/15 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Family | Plan Type: OAP Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)

• Acupuncture • Hearing aids • Routine eye care (Adults) • Bariatric surgery • Long-term care • Routine foot care • Cosmetic surgery • Non-emergency care when traveling outside the • Weight loss programs U.S. • Dental care (Adult)

Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)

• Chiropractic Service • Infertility treatment • Private-duty nursing

Your Rights to Continue Coverage: Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium . There are exceptions, however, such as if: • You commit fraud • The insurer stops offering services in the State • You move outside the coverage area For more information on your rights to continue coverage, contact the insurer at 1800-Cigna24. You may also contact your state insurance department at 800-203-3447.

Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance . For questions about your rights, this notice, or assistance, you can contact: Connecticut Department of Insurance at 1-800-203-3447.

Questions: Call 1-800-Cigna24 or visit us at www.cigna.com/individuals-families/connecticut If you aren’t clear about any of the bolded terms used in this form, see the Glossary. 6 of 9 You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy. Cigna Health and Life Insurance Company: CT myCigna Health Savings 6100 Coverage Period: 1/1/15-12/31/15 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Family | Plan Type: OAP

Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coverage.

Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides.

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–––––––––––––––––––––– To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––

Questions: Call 1-800-Cigna24 or visit us at www.cigna.com/individuals-families/connecticut If you aren’t clear about any of the bolded terms used in this form, see the Glossary. 7 of 9 You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy. Cigna Health and Life Insurance Company:Covered CT myCigna Health Savings 6100 Coverage Period: 1/1/15-12/31/15 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Family | Plan Type: OAP

About these Coverage Having a baby Managing type 2 diabetes (normal delivery) (routine maintenance of Examples: a well -controlled condition)

These examples show how this plan might cover Amount owed to providers: $7,540 Amount owed to providers: $5,400 medical care in given situations. Use these Plan pays $1,410 Plan pays $50 examples to see, in general, how much financial Patient pays $6,130 Patient pays $5,350 protection a sample patient might get if they are covered under different plans. Sample care costs: Sample care costs: Hospital charges (mother) $2,700 Prescriptions $2,900 Routine obstetric care $2,100 Medical Equipment and Supplies $1,300 Hospital charges (baby) $900 Office Visits and Procedures $700 This is Anesthesia $900 Education $300 not a cost Laboratory tests $500 Laboratory tests $100 estimator. Prescriptions $200 Vaccines, other preventive $100

Radiology $200 Total $5,400 Don’t use these examples to estimate your actual costs Vaccines, other preventive $40 under this plan. The actual Total $7,540 Patient pays: care you receive will be Deductibles $5,030 different from these Patient pays: Copays $0 examples, and the cost of Deductibles $6,100 Coinsurance $0 that care will also be Copays $0 Limits or exclusions $320 different. Coinsurance $0 Total $5,350 See the next page for Limits or exclusions $30 important information about Total $6,130 these examples.

Questions: Call 1-800-Cigna24 or visit us at www.cigna.com/individuals-families/connecticut If you aren’t clear about any of the bolded terms used in this form, see the Glossary. 8 of 9 You can view the Glossary at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy. Cigna Health and Life Insurance Company:Covered CT myCigna Health Savings 6100 Coverage Period: 1/1/15-12/31/15 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Family | Plan Type: OAP Questions and answers about the Coverage Examples:

What are some of the assumptions behind the What does a Coverage Example show? Can I use Coverage Examples to compare Coverage Examples? For each treatment situation, the Coverage plans? Example helps you see how deductibles , co- Yes. When you look at the Summary of • Costs don’t include premiums . payments , and co-insurance can add up. It also Benefits and Coverage for other plans, you’ll • Sample care costs are based on national helps you see what expenses might be left up to find the same Coverage Examples. When you averages supplied by the U.S. Department you to pay because the service or treatment isn’t compare plans, check the “Patient Pays” box of Health and Human Services, and aren’t covered or payment is limited. in each example. The smaller that number, specific to a particular geographic area or the more coverage the plan provides. health plan. • The patient’s condition was not an excluded or Does the Coverage Example predict my own preexisting condition. care needs? Are there other costs I should consider when • comparing plans? All services and treatments started and No. Treatments shown are just examples. The ended in the same coverage period. care you would receive for this condition could Yes. An important cost is the premium you • There are no other medical expenses for be different based on your doctor’s advice, pay. Generally, the lower your premium , the any member covered under this plan. your age, how serious your condition is, and more you’ll pay in out-of-pocket costs, such as • Out-of-pocket expenses are based only on many other factors. co-payments , deductibles , and co- treating the condition in the example. insurance . You should also consider • The patient received all care from in- Does the Coverage Example predict my future contributions to accounts such as health network providers . If the patient had expenses? savings accounts (HSAs), flexible spending received care from out-of-network arrangements (FSAs) or health providers , costs would have been higher. No. Coverage Examples are not cost reimbursement accounts (HRAs) that help you estimators. You can’t use the examples to pay out-of-pocket expenses. estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows.