To receive In-Network Medical Benefits, services must be provided by a Cigna Network Provider. A Cigna Network Provider is an institution, facility, agency or health care professional, which has contracted directly or indirectly with Cigna. Providers qualifying as Participating Providers may change from time to time. A list of the current Participating Providers is located online at www.mycigna.com. The Provider Organization is a network of Participating Providers.
When you enroll, you and each member of your family can select his or her own Primary Care Physician (PCP) from among the physicians in the network. All services must be provided or authorized by your PCP. See the most current listing of participating providers www.mycigna.com. You and your family members may be required to pay a portion of the covered expenses for services and supplies. That portion is the Co-payment. If you see a doctor who does not participate in the Cigna Network, you’ll be responsible for all associated costs.
If you are unable to locate a Cigna Network Provider in your area who can provide you with a service or supply that is covered under the Cigna OAPIN Option, you must call your PCP to obtain authorization for Out-of-Network Provider coverage. If you obtain authorization for services provided by an Out-of-Network Provider, those services will be covered at the In-Network benefit level.
Co-payments are expenses to be paid by you or your Family Member for the services received. Deductibles are also expenses to be paid by you or your Family Member. Deductible amounts are separate from and not reduced by Co-payments.
Annual out-of-pocket limit for prescription drugs
Once the out-of-pocket maximum has been reached, benefits for Prescription Drugs are payable at 100%.
Lifetime maximum benefit
The total maximum benefit per covered person is unlimited.
Contract Year means a period from January 1 to December 31 each calendar year.
Benefits for in-network medical care
(including mental illness and substance abuse, see In-network co-pay schedule for more information)
- You or your eligible Family Member pays any required Co-payment
- This Cigna OPAIN option pays 100% of all services and supplies authorized, as required, by the Primary Care Physician and the Provider Organization
Your PCP will provide your primary care and, when medically necessary, your PCP may refer you to other in network doctors or facilities for treatment. The referral is important because it is how your PCP arranges for you to receive necessary, appropriate care and follow-up treatment. While your plan does not require a referral from your PCP for you to see specialty doctors, you will want to coordinate such care with your PCP. Also, certain services do require prior authorization from Cigna. In such case, your doctor will coordinate the prior authorization process with Cigna on your behalf. You will not be required, nor expected, to manually track the prior authorization.
The term Prior Authorization means the approval that a Participating Provider must receive from Cigna in order for certain services and benefits to be covered under the Cigna OAPIN Option. Your PCP is responsible for obtaining authorization from Cigna for in-network covered services.
Services that require Prior Authorization include, but are not limited to:
- Inpatient Hospital Services;
- Inpatient Services at any Other Participating Healthcare Facility;
- Outpatient Facility Services;
- Magnetic Resonance Imaging (MRI);
- Nonemergency Ambulance; or
- Organ Transplant Services.
- Mental Health/Substance Abuse Treatment
Direct access for obstetric/gynecological services
Females covered by the Cigna OAPIN Option are allowed direct access to a licensed/certified Participating Provider for covered obstetric/gynecological services. There is no requirement to obtain an authorization of care from your Primary Care Physician for visits to a Participating Provider of your choice for pregnancy, well-woman gynecological exams, primary and preventive gynecological care, and acute gynecological conditions. Make sure that the OB/GYN is a Participating Provider prior to each visit and that any services that the OB/GYN requests will be In-Network under the Cigna OAPIN Option.