Management Science Associates Spds

SUMMARY OF BENEFITS
Cigna Health and Life Insurance Co.

For - Management Science Associates, Inc. Exchange Account
Open Access Plus Plan
Selection of a Primary Care Provider - your plan may require or allow the designation of a primary care provider. 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.mycigna.com or contact customer service at the phone number listed on the back of your ID card. 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 pre-approved
treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, visit
www.mycigna.com or contact customer service at the phone number listed on the back of your ID card.
Plan Highlights
Lifetime Maximum
Coinsurance
Maximum Reimbursable Charge
In-Network
Out-of-Network
Unlimited
Your plan pays 80%
Unlimited
Your plan pays 60%
Not Applicable
110%
Individual: $800
Individual: $2,400
Family: $1,600
Family: $4,800
Only the amount you pay for in-network covered expenses counts toward your in-network deductible. The amount you pay for out-of-network covered
expenses counts toward both your in-network and out-of-network deductibles.
After each eligible family member meets his or her individual deductible, covered expenses for that family member will be paid based on the coinsurance
level specified by the plan. Or, after the family deductible has been met, covered expenses for each eligible family member will be paid based on the
coinsurance level specified by the plan.
Note: Services where plan deductible applies are noted with a caret (^)
Calendar Year Deductible
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Plan Highlights
In-Network
Out-of-Network
Individual: $2,400
Individual: $4,800
Calendar Year Out-of-Pocket Maximum
Family: $4,800
Family: $9,600
Only the amount you pay for in-network covered expenses counts toward your in-network out-of-pocket maximum. The amount you pay for out-of-network
covered expenses counts toward both your in-network and out-of-network out-of-pocket maximums.
Plan deductible contributes towards your out-of-pocket maximum.
All copays and benefit deductibles contribute towards your out-of-pocket maximum.
Mental Health and Substance Use Disorder covered expenses contribute towards your out-of-pocket maximum.
After each eligible family member meets his or her individual out-of-pocket maximum, the plan will pay 100% of their covered expenses. Or, after the family
out-of-pocket maximum has been met, the plan will pay 100% of each eligible family member's covered expenses.
This plan includes a combined Medical/Pharmacy out-of-pocket maximum.
Retail and home delivery Pharmacy costs contribute to the combined Medical/Pharmacy out-of-pocket.
Benefit
In-Network
Out-of-Network
Physician Services
Physician Office Visit
All services including Lab & X-ray
Plan pays 100% after you pay copay
Surgery Performed in Physician's Office
Allergy Treatment/Injections
$40 Primary Care Physician (PCP) copay

or
$80 Specialist copay
$40 PCP or $80 Specialist copay
$40 PCP or $80 Specialist copay or actual
charge (if less)
Your plan pays 60% ^

Allergy Serum
Your plan pays 100%
Dispensed by the physician in the office
Cigna Telehealth Connection services
$40 copay
Not Covered
Includes charges for the delivery of medical and health-related consultations via secure telecommunications technologies, telephones and internet only when
delivered by contracted medical telehealth providers (see details on myCigna.com).
Preventive Care
Preventive Care
Your plan pays 100%
Includes coverage of additional services, such as urinalysis, EKG, and other laboratory tests, supplementing the standard Preventive Care benefit.
Immunizations
Your plan pays 100%
Mammogram, PAP, and PSA Tests
Your plan pays 100%
Coverage includes the associated Preventive Outpatient Professional Services.
Diagnostic-related services are covered at the same level of benefits as other x-ray and lab services, based on place of service.
Inpatient
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Benefit
In-Network
Out-of-Network
Inpatient Hospital Facility
Semi-Private Room: In-Network: Limited to the semi-private negotiated rate / Out-of-Network: Limited to semi-private rate
Private Room: In-Network: Limited to the semi-private negotiated rate / Out-of-Network: Limited to semi-private rate
Special Care Units (Intensive Care Unit (ICU), Critical Care Unit (CCU)): In-Network: Limited to the negotiated rate / Out-of-Network: Limited to ICU/CCU daily
room rate
Inpatient Hospital Physician's Visit/Consultation
Inpatient Professional Services
For services performed by Surgeons, Radiologists, Pathologists
and Anesthesiologists
Outpatient
Outpatient Facility Services
Outpatient Professional Services
Short-Term Rehabilitation
Calendar Year Maximums:

Pulmonary Rehabilitation, Cognitive Therapy and Cardiac Rehabilitation Unlimited days
Physical Therapy, Speech Therapy and Occupational Therapy 60 days
Chiropractic Care 30 days
Note: Therapy days, provided as part of an approved Home Health Care plan, accumulate to the applicable outpatient short term rehab therapy maximum.
Other Health Care Facilities/Services

Home Health Care
(includes outpatient private duty nursing subject to medical necessity)
120 days maximum per Calendar Year
16 hour maximum per day
Skilled Nursing Facility, Rehabilitation Hospital, Sub-Acute Facility
Durable Medical Equipment
Unlimited maximum per Calendar Year
Breast Feeding Equipment and Supplies
Limited to the rental of one breast pump per birth as ordered or
prescribed by a physician.
Includes related supplies
External Prosthetic Appliances (EPA)
Your plan pays 100%
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Benefit
In-Network
Out-of-Network
Routine Foot Disorders
Not Covered
Not Covered
Note: Services associated with foot care for diabetes and peripheral vascular disease are covered when medically necessary.
Acupuncture
Hearing Aid
$1,000 maximum per Calendar Year
Includes testing and fitting of hearing aid devices covered at PCP
or Specialist Office visit level.
Wigs
$300 maximum per Calendar Year
Place of Service - your plan pays based on where you receive services
Benefit
Emergency Room/ Urgent Care
Physician's Office
Independent Lab
Facility
Out-ofOut-ofOut-ofIn-Network
In-Network
In-Network
Network
Network
Network
$40 PCP or $80 Plan pays 60%
Plan pays 80%
Plan pays 60%
Plan pays 80% ^
Specialist copay ^
^
^
Outpatient Facility
In-Network
Out-ofNetwork
Plan pays 60%
^
Lab and XPlan pays 80%

ray
^
Advanced
Plan pays 60%
Plan pays 80%
Plan pays 60%
Radiology
Plan pays 100%
Not Applicable
Not Applicable
Plan pays 80% ^
^
^
^
Imaging
Advanced Radiology Imaging (ARI) includes MRI, MRA, CAT Scan, PET Scan, etc...
Note: All lab and x-ray services, including ARI, provided at Inpatient Hospital are covered under Inpatient Hospital benefit
Emergency Room / Urgent Care Facility
*Ambulance
Benefit
In-Network
Out-of-Network
In-Network
Out-of-Network
In-Network
Out-of-Network
Emergency
Plan pays 80% ^
Plan pays 80% ^
Plan pays 80% ^
Care
Urgent Care
Plan pays 80% ^
Plan pays 80% ^
Not Applicable
*Ambulance services used as non-emergency transportation (e.g., transportation from hospital back home) generally are not covered.
Inpatient Hospital and Other Health Care Facilities
Outpatient Services
Benefit
In-Network
Out-of-Network
In-Network
Out-of-Network
Hospice
Plan pays 80% ^
Plan pays 60% ^
Plan pays 80% ^
Plan pays 60% ^
Bereavement
Plan pays 80% ^
Plan pays 60% ^
Plan pays 80% ^
Plan pays 60% ^
Counseling
Note: Services provided as part of Hospice Care Program
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Benefit
Initial Visit to Confirm

Pregnancy
In-Network
Maternity
$40 PCP or $80

Specialist copay
Out-ofNetwork
Plan pays 60%
^
Global Maternity Fee

(All Subsequent Prenatal Visits,
Postnatal Visits and Physician's
Delivery Charges)
Out-ofIn-Network
Network
Plan pays 80%
^
Plan pays 60%

^
Office Visits in Addition to

Global Maternity Fee (Performed
by OB/GYN or Specialist)
Out-ofNetwork
In-Network
$40 PCP or $80
Specialist copay
Plan pays 60%

^
Delivery - Facility
(Inpatient Hospital, Birthing
Center)
In-Network
Covered same
as plan's
Inpatient
Hospital benefit
Out-ofNetwork
Covered same
as plan's
Inpatient
Hospital benefit
Physician's Office
Benefit
In-Network
Out-ofNetwork
Inpatient Facility
In-Network
Out-ofNetwork
Outpatient Facility
In-Network
Out-ofNetwork
Inpatient Professional
Services
Out-ofIn-Network
Network
Outpatient Professional
Services
Out-ofIn-Network
Network
Abortion
$40 PCP or
(Elective and
$80
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Specialist
60% ^
80% ^
60% ^
80% ^
60% ^
80% ^
60% ^
80% ^
60% ^
non-elective
procedures)
copay
Family
$40 PCP or
Planning $80
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Men's
Specialist
60% ^
80% ^
60% ^
80% ^
60% ^
80% ^
60% ^
80% ^
60% ^
Services
copay
Includes surgical services, such as vasectomy (excludes reversals)
Family
Planning Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Women's
100%
60% ^
100%
60% ^
100%
60% ^
100%
60% ^
100%
60% ^
Services
Includes surgical services, such as tubal ligation (excludes reversals)
Contraceptive devices as ordered or prescribed by a physician.
Infertility
Note: Coverage will be provided for the treatment of an underlying medical condition up to the point an infertility condition is diagnosed. Services will be covered as
any other illness.
$40 PCP or
TMJ, Surgical
$80
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
and NonSpecialist
60% ^
80% ^
60% ^
80% ^
60% ^
80% ^
60% ^
80% ^
60% ^
Surgical
copay
Services provided on a case-by-case basis. Always excludes appliances & orthodontic treatment. Subject to medical necessity.
Non-Surgical: Unlimited maximum per lifetime
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Physician's Office
Benefit
In-Network
Out-ofNetwork
Inpatient Facility
In-Network
Out-ofNetwork
Outpatient Facility
In-Network
Out-ofNetwork
Services
Out-ofIn-Network
Network
Services
Out-ofIn-Network
Network
$40 PCP or
$80
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Specialist
60% ^
80% ^
60% ^
80% ^
60% ^
80% ^
60% ^
80% ^
60% ^
copay
Surgeon Charges Lifetime Maximum: Unlimited
Treatment of clinically severe obesity, as defined by the body mass index (BMI) is covered.
The following are excluded:
medical and surgical services to alter appearances or physical changes that are the result of any surgery performed for the management of obesity or clinically
severe (morbid) obesity.
weight loss programs or treatments, whether prescribed or recommended by a physician or under medical supervision
Non-Lifesource
Non-Lifesource
Benefit
Lifesource Facility
Lifesource Facility
Facility
Out-of-Network
Facility
Out-of-Network
In-Network
In-Network
In-Network
In-Network
Organ
Plan pays 100%
Plan pays 80% ^
Plan pays 60% ^
Plan pays 100%
Plan pays 80% ^
Plan pays 60% ^
Transplants
Travel Maximum - Lifesource Facility: In-Network: $10,000 maximum per Transplant
Inpatient
Outpatient - Physician's Office
Outpatient All Other Services
Benefit
In-Network
Out-of-Network
In-Network
Out-of-Network
In-Network
Out-of-Network
Mental Health
Plan pays 80% ^
Plan pays 60% ^
$40 copay
Plan pays 60% ^
Plan pays 80% ^
Plan pays 60% ^
Substance Use
Plan pays 80% ^
Plan pays 60% ^
$40 copay
Plan pays 60% ^
Plan pays 80% ^
Plan pays 60% ^
Disorder
Note: Detox is covered under medical
Services are paid at 100% after you reach your out-of-pocket maximum.
Inpatient includes Residential Treatment.
Outpatient includes partial hospitalization and individual, intensive outpatient, behavioral telehealth consultation and group therapy.
Bariatric
Surgery
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Mental Health and Substance Use Disorder Services

Mental Health/Substance Use Disorder Utilization Review, Case Management and Programs
Cigna Total Behavioral Health - Inpatient and Outpatient Management
Inpatient utilization review and case management
Outpatient utilization review and case management
Partial Hospitalization
Intensive outpatient programs
Changing Lives by Integrating Mind and Body Program
Lifestyle Management Programs: Stress Management, Tobacco Cessation and Weight Management.
Narcotic Therapy Management
Complex Psychiatric Case Management
Pharmacy
In-Network
Cigna Pharmacy three-tier coinsurance plan

Retail drugs may be obtained In-Network at a wide range of
pharmacies across the nation.
When patient requests brand drug, patient pays the generic
coinsurance plus the cost difference between the brand and
generic drugs up to the cost of the brand drug.
Your pharmacy benefits have a combined out-of-pocket maximum
with the medical/behavioral benefits.
Self Administered injectable drugs - excludes infertility drugs
Oral contraceptives included
Includes oral contraceptives - with specific products covered 100%
Oral Fertility drugs included
Insulin, glucose test strips, lancets, insulin needles & syringes,
insulin pens and cartridges included
Specialty medications are limited to a 90-day supply for Home
Delivery
Specialty medications are limited to a 30-day supply at Retail
Retail - 30 day supply

Generic: You pay $10
Preferred Brand: You pay 30% subject to
a minimum of $25 and a maximum of $50
Non-Preferred Brand: You pay 45%
subject to a minimum of $40 and a
maximum of $80
Retail
You pay 40%
Your plan pays 60%
Out-of-Network
Home Delivery - 90 day supply

Generic: You pay $25
Preferred Brand: You pay 30% subject to
a minimum of $62 and a maximum of $125
subject to a minimum of $100 and a
maximum of $200
Home Delivery
Not Covered
Pharmacy Program Information

Pharmacy Clinical Management and Prior Authorization
Your plan is subject to refill-too-soon and other clinical edits as well as prior authorization requirements.
Plan exclusion edits are always included.
Additional clinical management - Basic package - provides a limited set of clinical edits such as prior authorization, age edits and quantity limits for a specific
list of prescription medications.
Prescription Drug List:
Your Cigna Standard Prescription Drug List includes a full range of drugs including all those required under applicable health care laws. To check which
drugs are included in your plan, please log on to myCigna.com.
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Specialty Pharmacy Management:
Clinical Programs
o Prior authorization is required on specialty medications but quantity limits may apply.
o Theracare Program
Medication Access Option
o Home Delivery Only (limited to 1 fill at Retail)
Additional Information
Case Management
Coordinated by Cigna HealthCare. This is a service designated to provide assistance to a patient who is at risk of developing medical complexities or for whom a
health incident has precipitated a need for rehabilitation or additional health care support. The program strives to attain a balance between quality and cost effective
care while maximizing the patient's quality of life.
Out-of-Network services are subject to a Calendar Year deductible and maximum reimbursable charge limitations. Payments made to health care professionals not
participating in Cigna's network are determined based on the lesser of: the health care professional's normal charge for a similar service or supply, or a percentage
(110%) of a fee schedule developed by Cigna that is based on a methodology similar to one used by Medicare to determine the allowable fee for the same or similar
service in a geographic area. In some cases, the Medicare based fee schedule is not used, and the maximum reimbursable charge for covered services is
determined based on the lesser of: the health care professional's normal charge for a similar service or supply, or the amount charged for that service by 80% of the
health care professionals in the geographic area where it is received. The health care professional may bill the customer the difference between the health care
professional's normal charge and the Maximum Reimbursable Charge as determined by the benefit plan, in addition to applicable deductibles, co-payments and
coinsurance.
Multiple Surgical Reduction
Multiple surgeries performed during one operating session result in payment reduction of 50% to the surgery of lesser charge. The most expensive procedure is paid
as any other surgery.
Pre-Certification - Continued Stay Review - PHS+ Inpatient - required for all inpatient admissions
In Network: Coordinated by your physician
Out-of-Network: Customer is responsible for contacting Cigna Healthcare. Subject to penalty/reduction or denial for non-compliance.
50% penalty applied to hospital inpatient charges for failure to contact Cigna Healthcare to precertify admission.
Benefits are denied for any admission reviewed by Cigna Healthcare and not certified.
Benefits are denied for any additional days not certified by Cigna Healthcare.
Pre-Certification - Continued Stay Review - PHS+ Outpatient Prior Authorization - required for selected outpatient procedures and diagnostic testing
50% penalty applied to outpatient procedures/diagnostic testing charges for failure to contact Cigna Healthcare and to precertify admission.
Benefits are denied for any outpatient procedures/diagnostic testing reviewed by Cigna Healthcare and not certified.
Pre-Existing Condition Limitation (PCL) does not apply.
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Your Health First - 200
Individuals with one or more of the chronic conditions, identified on the right, may
be eligible to receive the following type of support:
Condition Management
Medication adherence
Risk factor management
Lifestyle issues
Health & Wellness issues
Pre/post-admission
Treatment decision support
Gaps in care
Holistic health support for the following chronic health conditions:

Heart Disease
Coronary Artery Disease
Angina
Congestive Heart Failure
Acute Myocardial Infarction
Peripheral Arterial Disease
Asthma
Chronic Obstructive Pulmonary Disease (Emphysema and Chronic
Bronchitis)
Diabetes Type 1
Diabetes Type 2
Metabolic Syndrome/Weight Complications
Osteoarthritis
Low Back Pain
Anxiety
Bipolar Disorder
Depression
Definitions
Coinsurance - After you've reached your deductible, you and your plan share some of your medical costs. The portion of covered expenses you are responsible for
is called Coinsurance.
Copay - A flat fee you pay for certain covered services such as doctor's visits or prescriptions.
Deductible - A flat dollar amount you must pay out of your own pocket before your plan begins to pay for covered services.
Out-of-Pocket Maximum - Specific limits for the total amount you will pay out of your own pocket before your plan coinsurance percentage no longer applies. Once
you meet these maximums, your plan then pays 100 percent of the "Maximum Reimbursable Charges" or negotiated fees for covered services.
Prescription Drug List - The list of prescription brand and generic drugs covered by your pharmacy plan.
Transition of Care - Provides in-network health coverage to new customers when the customer's doctor is not part of the Cigna network and there are approved
clinical reasons why the customer should continue to see the same doctor.
Exclusions
What's Not Covered (not all-inclusive):
Your plan provides for most medically necessary services. The complete list of exclusions is provided in your Certificate or Summary Plan Description. To the extent
there may be differences, the terms of the Certificate or Summary Plan Description control. Examples of things your plan does not cover, unless required by law or
covered under the pharmacy benefit, include (but aren't limited to):
Care for health conditions that are required by state or local law to be treated in a public facility.
Care required by state or federal law to be supplied by a public school system or school district.
Care for military service disabilities treatable through governmental services if you are legally entitled to such treatment and facilities are reasonably
available.
Treatment of an Injury or Sickness which is due to war, declared, or undeclared, riot or insurrection.
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Exclusions
Charges which you are not obligated to pay or for which you are not billed or for which you would not have been billed except that they were covered under
this plan. For example, if Cigna determines that a provider is or has waived, reduced, or forgiven any portion of its charges and/or any portion of copayment,
deductible, and/or coinsurance amount(s) you are required to pay for a Covered Service (as shown on the Schedule) without Cigna's express consent, then
Cigna in its sole discretion shall have the right to deny the payment of benefits in connection with the Covered Service, or reduce the benefits in proportion to
the amount of the copayment, deductible, and/or coinsurance amounts waived, forgiven or reduced, regardless of whether the provider represents that you
remain responsible for any amounts that your plan does not cover. In the exercise of that discretion, Cigna shall have the right to require you to provide proof
sufficient to Cigna that you have made your required cost share payment(s) prior to the payment of any benefits by Cigna. This exclusion includes, but is not
limited to, charges of a Non-Participating Provider who has agreed to charge you or charged you at an in-network benefits level or some other benefits level
not otherwise applicable to the services received.
Charges arising out of or related to any violation of a healthcare-related state or federal law or which themselves are a violation of a healthcare-related state
or federal law.
Assistance in the activities of daily living, including but not limited to eating, bathing, dressing or other Custodial Services or self-care activities, homemaker
services and services primarily for rest, domiciliary or convalescent care.
For or in connection with experimental, investigational or unproven services.
Experimental, investigational and unproven services are medical, surgical, diagnostic, psychiatric, substance use disorder or other health care technologies,
supplies, treatments, procedures, drug therapies or devices that are determined by the utilization review Physician to be:
o Not demonstrated, through existing peer-reviewed, evidence-based, scientific literature to be safe and effective for treating or diagnosing the
condition or sickness for which its use is proposed;
o Not approved by the U.S. Food and Drug Administration (FDA) or other appropriate regulatory agency to be lawfully marketed for the proposed use;
o The subject of review or approval by an Institutional Review Board for the proposed use except as provided in the "Clinical Trials" section of this plan;
or
o The subject of an ongoing phase I, II or III clinical trial, except for routine patient care costs related to qualified clinical trials as provided in the
"Clinical Trials" section(s) of this plan.
Cosmetic surgery and therapies. Cosmetic surgery or therapy is defined as surgery or therapy performed to improve or alter appearance.
The following services are excluded from coverage regardless of clinical indications: Macromastia or Gynecomastia Surgeries; Abdominoplasty;
Panniculectomy; Rhinoplasty; Blepharoplasty; Removal of skin tags; Acupressure; Craniosacral/cranial therapy; Dance therapy, Movement therapy; Applied
kinesiology; Rolfing; Prolotherapy; and Extracorporeal shock wave lithotripsy (ESWL) for musculoskeletal and orthopedic conditions.
Dental treatment of the teeth, gums or structures directly supporting the teeth, including dental X-rays, examinations, repairs, orthodontics, periodontics,
casts, splints and services for dental malocclusion, for any condition. Charges made for services or supplies provided for or in connection with an accidental
injury to sound natural teeth are covered provided a continuous course of dental treatment is started within six months of an accident. Sound natural teeth are
defined as natural teeth that are free of active clinical decay, have at least 50% bony support and are functional in the arch.
Medical and surgical services, initial and repeat, intended for the treatment or control of obesity, except for treatment of clinically severe (morbid) obesity as
shown in Covered Expenses, including: medical and surgical services to alter appearance or physical changes that are the result of any surgery performed
for the management of obesity or clinically severe (morbid) obesity; and weight loss programs or treatments, whether prescribed or recommended by a
Physician or under medical supervision.
Unless otherwise covered in this plan, for reports, evaluations, physical examinations, or hospitalization not required for health reasons including, but not
limited to, employment, insurance or government licenses, and court-ordered, forensic or custodial evaluations.
Court-ordered treatment or hospitalization, unless such treatment is prescribed by a Physician and listed as covered in this plan.
Infertility services including infertility drugs, surgical or medical treatment programs for infertility, including in vitro fertilization, gamete intrafallopian transfer
(GIFT), zygote intrafallopian transfer (ZIFT), variations of these procedures, and any costs associated with the collection, washing, preparation or storage of
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Exclusions
sperm for artificial insemination (including donor fees). Cryopreservation of donor sperm and eggs are also excluded from coverage.
Reversal of male or female voluntary sterilization procedures.
Transsexual surgery including medical or psychological counseling and hormonal therapy in preparation for, or subsequent to, any such surgery.
Any medications, drugs, services or supplies for the treatment of male or female sexual dysfunction such as, but not limited to, treatment of erectile
dysfunction (including penile implants), anorgasmy, and premature ejaculation.
Medical and Hospital care and costs for the infant child of a Dependent, unless this infant child is otherwise eligible under this plan.
Nonmedical counseling or ancillary services, including but not limited to Custodial Services, education, training, vocational rehabilitation, behavioral training,
biofeedback, neurofeedback, hypnosis, sleep therapy, employment counseling, back school, return to work services, work hardening programs, driving
safety, and services, training, educational therapy or other nonmedical ancillary services for learning disabilities, developmental delays, autism or intellectual
disabilities.
Therapy or treatment intended primarily to improve or maintain general physical condition or for the purpose of enhancing job, school, athletic or recreational
performance, including but not limited to routine, long term, or maintenance care which is provided after the resolution of the acute medical problem and
when significant therapeutic improvement is not expected.
Consumable medical supplies other than ostomy supplies and urinary catheters. Excluded supplies include, but are not limited to bandages and other
disposable medical supplies, skin preparations and test strips, except as specified in the "Home Health Services" or "Breast Reconstruction and Breast
Prostheses" sections of this plan.
Private Hospital rooms and/or private duty nursing except as provided under the Home Health Services provision.
Personal or comfort items such as personal care kits provided on admission to a Hospital, television, telephone, newborn infant photographs, complimentary
meals, birth announcements, and other articles which are not for the specific treatment of an Injury or Sickness.
Artificial aids including, but not limited to, corrective orthopedic shoes, arch supports, elastic stockings, garter belts, corsets, dentures and wigs.
Aids or devices that assist with nonverbal communications, including but not limited to communication boards, prerecorded speech devices, laptop
computers, desktop computers, Personal Digital Assistants (PDAs), Braille typewriters, visual alert systems for the deaf and memory books.
Eyeglass lenses and frames and contact lenses (except for the first pair of contact lenses for treatment of keratoconus or post cataract surgery).
Routine refractions, eye exercises and surgical treatment for the correction of a refractive error, including radial keratotomy.
All non-injectable prescription drugs, injectable prescription drugs that do not require Physician supervision and are typically considered self-administered
drugs, nonprescription drugs, and investigational and experimental drugs, except as provided in this plan.
Routine foot care, including the paring and removing of corns and calluses or trimming of nails. However, services associated with foot care for diabetes and
peripheral vascular disease are covered when Medically Necessary.
Membership costs or fees associated with health clubs, weight loss programs and smoking cessation programs.
Genetic screening or pre-implantations genetic screening. General population-based genetic screening is a testing method performed in the absence of any
symptoms or any significant, proven risk factors for genetically linked inheritable disease.
Dental implants for any condition.
Fees associated with the collection or donation of blood or blood products, except for autologous donation in anticipation of scheduled services where in the
utilization review Physician's opinion the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery.
Blood administration for the purpose of general improvement in physical condition.
Cost of biologicals that are immunizations or medications for the purpose of travel, or to protect against occupational hazards and risks.
Cosmetics, dietary supplements and health and beauty aids.
All nutritional supplements and formulae except for infant formula needed for the treatment of inborn errors of metabolism.
Medical treatment for a person age 65 or older, who is covered under this plan as a retiree, or their Dependent, when payment is denied by the Medicare
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Cigna 2016
Exclusions
plan because treatment was received from a nonparticipating provider.

Medical treatment when payment is denied by a Primary Plan because treatment was received from a nonparticipating provider.
For or in connection with an Injury or Sickness arising out of, or in the course of, any employment for wage or profit.
Charges for the delivery of medical and health-related services via telecommunications technologies, including telephone and internet, unless provided as
specifically described under the benefit section.
Massage therapy.
These are only the highlights

This summary outlines the highlights of your plan. For a complete list of both covered and not covered services, including benefits required by your state, see your
employer's insurance certificate or summary plan description -- the official plan documents. If there are any differences between this summary and the plan
documents, the information in the plan documents takes precedence. This summary provides additional information not provided in the Summary of Benefits and
Coverage document required by the Federal Government.
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance
Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C. and HMO or service
company subsidiaries of Cigna Health Corporation. "Cigna Home Delivery Pharmacy" refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C. The Cigna name,
logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.
EHB State: PA
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Cigna 2016
Management Science Associates, Inc. Exchange Account:

Open Access Plus
Coverage Period: 01/01/2017 - 12/31/2017
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage for: Individual/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/sp/ or by calling 1-800-Cigna24
Important Questions
What is the overall
deductible?
Are there other deductibles
for specific services?
Answers
For in-network providers $800 person / $1,600 family
For out-of-network providers $2,400 person / $4,800
family
Does not apply to in-network preventive care &
immunizations, in-network office visits, prescription drugs
Co-payments don't count toward the deductible.
No.
Yes. For in-network providers $2,400 person / $4,800

Is there an out-of-pocket limit family
on my expenses?
family
What is not included in the
Premium, balance-billed charges, penalties for no preout-of-pocket limit?
authorization, and health care this plan doesn't cover.
Is there an overall annual
No.
limit on what the plan pays?
Does this plan use a network
of providers?
Yes. For a list of participating providers, see

www.myCigna.com or call 1-800-Cigna24
Do I need a referral to see a

specialist?
No. You don't need a referral to see a specialist.
Why this Matters:

You must pay all the costs up to the deductible amount before this plan
begins to pay for covered services you use. Check your policy or plan
document to see when the deductible starts over (usually, but not
always, January 1st). See the chart starting on page 2 for how much you
pay for covered services after you meet the deductible.
You don't have to meet deductibles for specific services, but see the
chart starting on page 2 for other costs for services this plan covers.
The out-of-pocket limit is the most you could pay during a coverage
period (usually one year) for your share of the cost of covered services.
This limit helps you plan for health care expenses.
Even though you pay these expenses, they don't count toward the out-ofpocket limit.
The chart starting on page 2 describes any limits on what the plan will pay
for specific covered services, such as office visits.
If you use an in-network doctor or other health care provider, this plan will
pay some or all of the costs of covered services. Be aware, your innetwork doctor or hospital may use an out-of-network provider for some
services. Plans use the term in-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.
You can see the specialist you choose without permission from this plan.
Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com.

If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.cciio.cms.gov or call 1-800-Cigna24 to request a copy.
1 of 8
Important Questions
Answers
Are there services this plan

doesn't cover?
Yes.
Why this Matters:

Some of the services this plan doesn't cover are listed on page 5. See
your policy or plan document for additional information about excluded
services.
Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount of the service. For example, if the health
plan's allowed amount for an overnight hospital stay is $1,000, your co-insurance 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 charge is $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 in-network providers by charging you lower deductibles, co-payments and co-insurance amounts.
Common Medical Event
If you visit a health care

provider's office or clinic
If you have a test
Services You May Need
Your Cost if you use an

In-Network Provider
Out-of-Network Provider
Primary care visit to treat an

$40 co-pay/visit
injury or illness
Specialist visit
$80 co-pay/visit
40% co-insurance
-----------none-----------
40% co-insurance
-----------none----------Coverage for Chiropractic care is

limited to 30 days annual max.
Other practitioner office visit $80 co-pay/visit for chiropractor 40% co-insurance
Preventive care/screening/
No charge
immunization
Diagnostic test (x-ray, blood
20% co-insurance
work)
Imaging (CT/PET scans,
20% co-insurance
MRIs)
Limitations & Exceptions
40% co-insurance
-----------none-----------
40% co-insurance
-----------none-----------
40% co-insurance
50% penalty for no precertification.

2 of 8

Generic drugs
If you need drugs to treat

your illness or condition
Preferred brand drugs
More information about

prescription drug
coverage is available at
www.myCigna.com
Non-preferred brand drugs
Facility fee (e.g.,

ambulatory surgery center)
Physician/surgeon fees
Emergency room services
If you need immediate
Emergency medical
medical attention
transportation
Urgent care
Facility fee (e.g., hospital
If you have a hospital stay room)
If you have outpatient
surgery

In-Network Provider
$10/prescription (retail),
40% co-insurance
$25/prescription (home
delivery)
30% co-insurance but not less
than $25 or greater than
$50/prescription (retail), 30%
co-insurance but not less than 40% co-insurance
$62 or greater than
delivery)
45% co-insurance but not less
than $40 or greater than
$80/prescription (retail), 45%
co-insurance but not less than 40% co-insurance
$100 or greater than
delivery)
Coverage is limited up to a 30-day

supply (retail) and a 90-day supply
(home delivery).
Certain limitations may apply,
including, for example: prior
authorization, step therapy, quantity
limits.
20% co-insurance
40% co-insurance
20% co-insurance
20% co-insurance
40% co-insurance
20% co-insurance

-----------none-----------
20% co-insurance
20% co-insurance
-----------none-----------
20% co-insurance
20% co-insurance
-----------none-----------
20% co-insurance
40% co-insurance
20% co-insurance
40% co-insurance

3 of 8

Mental/Behavioral health
outpatient services
If you have mental health,

behavioral health, or
substance abuse needs
If you are pregnant
If you need help

recovering or have other
special health needs

In-Network Provider
$40 co-pay/office visit and 20%
co-insurance/other outpatient
40% co-insurance
services
inpatient services
20% co-insurance
Substance use disorder

outpatient services
inpatient services
Prenatal and postnatal care
Delivery and all inpatient
services

50% penalty if no precert of nonroutine services (i.e., partial
hospitalization, IOP, etc.).
40% co-insurance
$40 co-pay/office visit and 20%

co-insurance/other outpatient
services
40% co-insurance

20% co-insurance
40% co-insurance
20% co-insurance
40% co-insurance
-----------none-----------
20% co-insurance
40% co-insurance
Home health care
20% co-insurance
40% co-insurance
Rehabilitation services
$80 co-pay/visit
40% co-insurance
Habilitation services
Not Covered
Not Covered
Skilled nursing care
20% co-insurance
40% co-insurance
Durable medical equipment

Hospice services
20% co-insurance
20% co-insurance
40% co-insurance
40% co-insurance


Coverage is limited to 120 days
annual max. Maximums crossaccumulate.
50% penalty for failure to precertify
speech therapy services. Coverage is
limited to annual max of: Unlimited
days for Pulmonary rehab, Cognitive
therapy and Cardiac rehab services;
60 days for Physical, Speech &
Occupational therapies
-----------none----------50% penalty for no precertification.
annual max.
4 of 8
If your child needs dental

or eye care
Eye Exam
Glasses
Dental check-up

In-Network Provider
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered

-----------none---------------------none---------------------none-----------
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.)
Cosmetic surgery
Routine eye care (Adult)
Dental care (Adult)
Infertility treatment
Routine foot care
Dental care (Children)
Long-term care
Weight loss programs
Eye care (Children)
Non-emergency care when traveling outside the U.S.
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.)
Acupuncture
Chiropractic care
Hearing aids
Bariatric surgery

5 of 8
Your Rights to Continue Coverage:

If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage.
Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the
plan. Other limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at 1-800-Cigna24. You may also contact your state insurance department, the U.S.
Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1877-267-2323 x61565 or www.cciio.cms.gov.
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 Cigna Customer service at 1-800-Cigna24. You may also contact the Department of Labor's Employee Benefits
Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Additionally, a consumer assistance program can help you file your appeal.
Contact the program for this plan's situs state: Pennsylvania Consumer Assistance Program at 877-881-6388. However, for information regarding your own state's
consumer assistance program refer to www.healthcare.gov.
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.
Language Access Services:

Spanish (Espaol): Para obtener asistencia en Espaol, llame al 1-800-244-6224.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-244-6224.
Chinese (): 1-800-244-6224.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-244-6224.
----------------------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.myCigna.com.
6 of 8
Coverage Examples
About these Coverage Examples:
These examples show how this plan might cover
medical care in given situations. Use these examples
to see, in general, how much financial protection a
sample patient might get if they are covered under
different plans.
This is not a cost estimator.

Don't use these examples to estimate your
actual costs under this plan. The actual care you
receive will be different from these examples, and
the cost of that care will also be different.
See the next page for important information about
these examples.
Note: These numbers assume enrollment in
individual-only coverage.
Having a baby
Managing type 2 diabetes
(normal delivery)
Amount owed to providers: $7,540
Plan pays: $5,330
Patient pays: $2,210
Sample care costs:
Hospital charges (mother)
$2,700
Routine Obstetric Care
$2,100
Hospital charges (baby)
$900
Anesthesia
$900
Laboratory tests
$500
Prescriptions
$200
Radiology
$200
Vaccines, other preventive
$40
Total
$7,540
Patient pays:
Deductible
Co-pays
Co-insurance
Limits or exclusions
Total
$800
$100
$1,280
$30
$2,210
(routine maintenance of a well-controlled

condition)
Plan pays: $3,960
Sample care costs:
Prescriptions
$2,900
Medical equipment and supplies
$1,300
Office visits & procedures
$700
Education
$300
Laboratory tests
$100
$100
Total
$5,400
Patient pays:
Deductible
Co-pays
Co-insurance
Total

$140
$1,020
$0
$280
$1,440
7 of 8
Questions and answers about the Coverage Examples:

What are some of the assumptions behind
the Coverage Examples?
Costs don't include premiums.

Sample care costs are based on national
averages supplied by the U.S. Department of
Health and Human Services, and aren't
specific to a particular geographic area or
health plan.
The patient's condition was not an excluded
or pre existing condition.
All services and treatments started and
ended in the same coverage period.
There are no other medical expenses for any
member covered under this plan.
Out-of-pocket expenses are based only on
treating the condition in the example.
The patient received all care from in-network
providers. If the patient had received care
from out-of-network providers, costs would
have been higher.
What does a Coverage Example show?

For each treatment situation, the Coverage Example
helps you see how deductibles, co-payments, and
co-insurance can add up. It also helps you see what
expenses might be left up to you to pay because the
service or treatment isn't covered or payment is
limited.
Does the Coverage Example predict my

own care needs?
No. Treatments shown are just examples. The

care you would receive for this condition could be
different based on your doctor's advice, your age,
how serious your condition is, and many other
factors.

future expenses?
No. Coverage Examples are not cost estimators.
Can I use Coverage Examples to compare

plans?
Yes. When you look at the Summary of Benefits

and Coverage for other plans, you'll find the same
Coverage Examples. When you compare plans, check
the "Patient Pays" box in each example. The smaller
that number, the more coverage the plan provides.
Are there other costs I should consider

when comparing plans?
Yes. An important cost is the premium you pay.

Generally, the lower your premium, the more you'll
pay in out-of-pocket costs, such as co-payments,
deductibles, and co-insurance. You also should
consider contributions to accounts such as health
savings accounts (HSAs), flexible spending
arrangements (FSAs) or health reimbursement
accounts (HRAs) that help you pay out-of-pocket
expenses.
You can't use the examples to 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.
Plan ID: 5337636 BenefitVersion: 8
Plan Name: $800 Deductible
Kit Track: SBM25269

8 of 8
SUMMARY OF BENEFITS
Plan Highlights
Lifetime Maximum
Coinsurance
In-Network
Out-of-Network
Unlimited
Your plan pays 80%
Unlimited
Your plan pays 60%
Not Applicable
110%
Individual: $1,850
Individual: $3,700
Family: $3,700
Family: $7,400
All eligible family members contribute towards the family plan deductible. Once the family deductible has been met, the plan will pay each eligible family
member's covered expenses based on the coinsurance level specified by the plan.
This plan includes a combined Medical/Pharmacy plan deductible.
Retail and home delivery Pharmacy costs contribute to the combined Medical/Pharmacy deductible.
Prescription medications used to prevent any of the following medical conditions are not subject to the individual and/or family plan deductible: hypertension,
high cholesterol, diabetes, asthma, osteoporosis, stroke, prenatal nutrient deficiency .
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Open Access Plus - Coinsurance - $1,850 Deductible HSA Plan - 5337622. Version# 8
KitTrak: CSM11459
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Cigna 2016
Plan Highlights
In-Network
Out-of-Network
Individual: $3,500
Individual: $7,000
Family: $6,500
Family: $13,000
All eligible family members contribute towards the family out-of-pocket maximum. Once the family out-of-pocket maximum has been met, the plan will pay
each eligible family member's covered expenses at 100%.
Benefit
In-Network
Out-of-Network
Physician Services
Allergy Serum
Not Covered
Preventive Care
Preventive Care
Your plan pays 100%
Immunizations
Your plan pays 100%
Your plan pays 100%
Inpatient
room rate
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Benefit
In-Network
Out-of-Network
Outpatient
Pulmonary Rehabilitation and Cognitive Therapy Unlimited days
Cardiac Rehabilitation - Unlimited days
Chiropractic Care - 30 days

Note: Includes treatment of Autism. Therapy days, provided as part of an approved Home Health Care plan, accumulate to the applicable outpatient short term rehab
therapy maximum.

Home Health Care
Outpatient Private Duty Nursing
Your plan pays 100%
Not Covered
Not Covered
Acupuncture
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Cigna 2016
Benefit
In-Network
Hearing Aid
Wigs
Out-of-Network
Benefit
Physician's Office
Independent Lab
Facility
In-Network
In-Network
Network
Network
Network
Plan pays 80%
Plan pays 60%
Plan pays 80%
Plan pays 60%
Plan pays 80% ^
^
^
^
^
Outpatient Facility
In-Network
Out-ofNetwork
Plan pays 60%
^

ray
^
Advanced
Plan pays 80%
Plan pays 60%
Plan pays 80%
Plan pays 60%
Radiology
Not Applicable
Not Applicable
Plan pays 80% ^
^
^
^
^
Imaging
*Ambulance
Benefit
In-Network
Out-of-Network
In-Network
Out-of-Network
In-Network
Out-of-Network
Emergency
Plan pays 80% ^
Plan pays 80% ^
Plan pays 80% ^
Care
Urgent Care
Plan pays 80% ^
Plan pays 80% ^
Not Applicable
Outpatient Services
Benefit
In-Network
Out-of-Network
In-Network
Out-of-Network
Hospice
Plan pays 80% ^
Plan pays 60% ^
Plan pays 80% ^
Plan pays 60% ^
Bereavement
Plan pays 80% ^
Plan pays 60% ^
Plan pays 80% ^
Plan pays 60% ^
Counseling
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Benefit

Pregnancy
In-Network
Maternity
Plan pays 80%

^
Out-ofNetwork
Plan pays 60%
^

Delivery Charges)
Out-ofIn-Network
Network
Plan pays 80%
^
Plan pays 60%

^

In-Network
Plan pays 80%
^
Out-ofNetwork
Plan pays 60%
^
Delivery - Facility
Center)
In-Network
Covered same
as plan's
Inpatient
Hospital benefit
Out-ofNetwork
Covered same
as plan's
Inpatient
Hospital benefit
Physician's Office
Benefit
In-Network
Out-ofNetwork
Inpatient Facility
In-Network
Out-ofNetwork
Outpatient Facility
In-Network
Out-ofNetwork
Services
Out-ofIn-Network
Network
Services
Out-ofIn-Network
Network
Abortion
(Elective and
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
80% ^
60% ^
80% ^
60% ^
80% ^
60% ^
80% ^
60% ^
80% ^
60% ^
non-elective
procedures)
Family
Planning Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Men's
80% ^
60% ^
80% ^
60% ^
80% ^
60% ^
80% ^
60% ^
80% ^
60% ^
Services
Family
Planning Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Women's
100%
60% ^
100%
60% ^
100%
60% ^
100%
60% ^
100%
60% ^
Services
Infertility
any other illness.
Bariatric
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Surgery
80% ^
60% ^
80% ^
60% ^
80% ^
60% ^
80% ^
60% ^
80% ^
60% ^
Surgeon Charges Lifetime Maximum: Unlimited
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Physician's Office
Inpatient Facility
Outpatient Facility
Benefit
Out-ofOut-ofIn-Network
In-Network
Network
Network
Non-Lifesource
Benefit
Lifesource Facility
Facility
Out-of-Network
In-Network
In-Network
In-Network
Organ
Transplants
Plan pays 100%
Plan pays 80% ^
Plan pays 60% ^
Out-ofNetwork
Services
Out-ofIn-Network
Network
Services
Out-ofIn-Network
Network

Non-Lifesource
Lifesource Facility
Facility
Out-of-Network
In-Network
In-Network
Plan pays 60% ^ up to
the following
transplant maximums:
Plan pays 100%
Plan pays 80% ^
Bone Marrow $130,000

Heart - $150,000
Heart/Lung - $185,000
Kidney - $80,000
Kidney/Pancreas $80,000 Liver $230,000
Lung - $185,000
Pancreas - $50,000

Inpatient
Benefit
In-Network
Out-of-Network
In-Network
Out-of-Network
In-Network
Out-of-Network
Mental Health
Plan pays 80% ^
Plan pays 60% ^
Plan pays 80% ^
Plan pays 60% ^
Plan pays 80% ^
Plan pays 60% ^
Substance Use
Plan pays 80% ^
Plan pays 60% ^
Plan pays 80% ^
Plan pays 60% ^
Plan pays 80% ^
Plan pays 60% ^
Disorder
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Cigna 2016

Pharmacy
Patient pays the brand coinsurance plus the cost difference
between the brand and generic drugs up to the cost of the brand
drug.
Your pharmacy benefits have a combined annual deductible and
out-of-pocket maximum with the medical/behavioral benefits. The
applicable cost share for covered drugs applies after the combined
deductible has been met.
Mandatory home delivery: Maintenance medications, including
oral contraceptives, must be filled through home delivery;
otherwise after 3 retail fills you pay the entire cost of the
prescription
Delivery
In-Network
Out-of-Network

Generic: You pay 20%
Preferred Brand: You pay 20%
Retail -30 day supply


Home Delivery
Not Covered
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Clinical Programs
o Theracare Program
Case Management
coinsurance.
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Heart Disease
Angina
Lifestyle issues
Asthma
Pre/post-admission
Bronchitis)
Diabetes Type 1
Gaps in care
Diabetes Type 2
Osteoarthritis
Low Back Pain
Anxiety
Bipolar Disorder
Depression
Definitions
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Exclusions
available.
or federal law.
or
Panniculectomy; Rhinoplasty; Blepharoplasty; Acupressure; Craniosacral/cranial therapy; Dance therapy, Movement therapy; Applied kinesiology; Rolfing;
Prolotherapy; and Extracorporeal shock wave lithotripsy (ESWL) for musculoskeletal and orthopedic conditions.
Surgical or nonsurgical treatment of TMJ disorders.
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Exclusions
safety, and services, training, educational therapy or other nonmedical ancillary services for learning disabilities, developmental delays, autism (except as
provided in Short-Term Rehabilitation section of covered services) or mental retardation.
Private Hospital rooms except as provided under the Home Health Services provision.
Artificial aids including, but not limited to, corrective orthopedic shoes, arch supports, elastic stockings, garter belts, corsets, dentures.
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Exclusions
Massage therapy.

EHB State: PA
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Open Access Plus
Coverage Period: 01/01/2017 - 12/31/2017
Important Questions
What is the overall

deductible?

Answers
For in-network providers $1,850 person / $3,700 family
family
Deductible per person applies when the employee is the
only person covered under the plan.
immunizations
No.

on my expenses?
family
No.
of providers?


specialist?
Why this Matters:


1 of 8
Important Questions
Answers

doesn't cover?
Yes.
Why this Matters:

services.

If you have a test

In-Network Provider

20% co-insurance
injury or illness
Specialist visit
20% co-insurance
20% co-insurance for
Other practitioner office visit
chiropractor
No charge
immunization
20% co-insurance
work)
20% co-insurance
MRIs)
40% co-insurance
-----------none-----------
40% co-insurance

40% co-insurance
40% co-insurance
-----------none-----------
40% co-insurance
-----------none-----------
40% co-insurance

2 of 8

Generic drugs

prescription drug
www.myCigna.com

Facility fee (e.g.,
Emergency medical
medical attention
transportation
Urgent care
surgery

In-Network Provider
20% co-insurance/prescription
(retail), 20% co20% co-insurance (retail only)
insurance/prescription (home
delivery)
delivery)
delivery)

(home delivery).
limits.
20% co-insurance
40% co-insurance
20% co-insurance
20% co-insurance
40% co-insurance
20% co-insurance

-----------none-----------
20% co-insurance
20% co-insurance
-----------none-----------
20% co-insurance
20% co-insurance
-----------none-----------
20% co-insurance
40% co-insurance
20% co-insurance
40% co-insurance

3 of 8

If you are pregnant
If you need help


In-Network Provider
outpatient services
20% co-insurance
40% co-insurance

inpatient services
20% co-insurance
40% co-insurance
20% co-insurance
40% co-insurance

20% co-insurance
40% co-insurance
20% co-insurance
40% co-insurance
-----------none-----------
20% co-insurance
40% co-insurance

outpatient services
inpatient services
services
Home health care
20% co-insurance
40% co-insurance
20% co-insurance
40% co-insurance
Not Covered
Not Covered
20% co-insurance
40% co-insurance

Hospice services
20% co-insurance
20% co-insurance
40% co-insurance
40% co-insurance


days for Pulmonary rehab and
Cognitive therapy; 60 days for
Physical, Speech & Occupational
therapies; Unlimited days for Cardiac
rehab services
annual max.
4 of 8

or eye care
Eye Exam
Glasses
Dental check-up

In-Network Provider
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered

-----------none---------------------none---------------------none-----------

Cosmetic surgery
Dental care (Adult)
Routine foot care
Long-term care
Eye care (Children)
Acupuncture
Chiropractic care
Hearing aids
Bariatric surgery

5 of 8





Chinese (): 1-800-244-6224.
6 of 8
Coverage Examples
different plans.

these examples.
Having a baby
(normal delivery)
Plan pays: $4,550
Sample care costs:
$2,700
$2,100
$900
Anesthesia
$900
Laboratory tests
$500
Prescriptions
$200
Radiology
$200
$40
Total
$7,540
Patient pays:
Deductible
Co-pays
Co-insurance
Total
$1,850
$0
$1,110
$30
$2,990

condition)
Plan pays: $2,630
Sample care costs:
Prescriptions
$2,900
$1,300
$700
Education
$300
Laboratory tests
$100
$100
Total
$5,400
Patient pays:
Deductible
Co-pays
Co-insurance
Total

$1,850
$0
$640
$280
$2,770
7 of 8


health plan.
have been higher.

limited.

own care needs?

factors.

future expenses?

plans?



expenses.

allows.
Plan Name: $1,850 Deductible HSA Plan
Kit Track: SBM25270

8 of 8
SUMMARY OF BENEFITS
Plan Highlights
Lifetime Maximum
Coinsurance
In-Network
Out-of-Network
Unlimited
Your plan pays 70%
Unlimited
Your plan pays 50%
Not Applicable
110%
Individual: $2,850
Individual: $5,700
Family: $5,700
Family: $11,400
After each eligible family member meets his or her individual deductible, covered expenses for that family member will be paid based on the coinsurance
level specified by the plan. Or, after the family deductible has been met, covered expenses for each eligible family member will be paid based on the
coinsurance level specified by the plan.
1/1/2017
ASO
KitTrak: CSM11460
1 of 12
Cigna 2016
Plan Highlights
In-Network
Out-of-Network
Individual: $5,500
Individual: $11,000
Family: $11,000
Family: $22,000
After each eligible family member meets his or her individual out-of-pocket maximum, the plan will pay 100% of their covered expenses. Or, after the family
out-of-pocket maximum has been met, the plan will pay 100% of each eligible family member's covered expenses.
Benefit
In-Network
Out-of-Network
Physician Services
Allergy Serum
Not Covered
Preventive Care
Preventive Care
Your plan pays 100%
Immunizations
Your plan pays 100%
Your plan pays 100%
Inpatient
room rate
1/1/2017
ASO
KitTrak: CSM11460
2 of 12
Cigna 2016
Benefit
In-Network
Out-of-Network
Outpatient
Pulmonary Rehabilitation and Cognitive Therapy Unlimited days
Cardiac Rehabilitation - Unlimited days
Chiropractic Care - 30 days

Note: Includes treatment of Autism. Therapy days, provided as part of an approved Home Health Care plan, accumulate to the applicable outpatient short term rehab
therapy maximum.

Home Health Care
Outpatient Private Duty Nursing
Your plan pays 100%
Not Covered
Not Covered
Acupuncture
1/1/2017
ASO
KitTrak: CSM11460
3 of 12
Cigna 2016
Benefit
In-Network
Hearing Aid
Wigs
Out-of-Network
Benefit
Physician's Office
Independent Lab
Facility
In-Network
In-Network
Network
Network
Network
Plan pays 70%
Plan pays 50%
Plan pays 70%
Plan pays 50%
Plan pays 70% ^
^
^
^
^
Outpatient Facility
In-Network
Out-ofNetwork
Plan pays 50%
^

ray
^
Advanced
Plan pays 70%
Plan pays 50%
Plan pays 70%
Plan pays 50%
Radiology
Not Applicable
Not Applicable
Plan pays 70% ^
^
^
^
^
Imaging
*Ambulance
Benefit
In-Network
Out-of-Network
In-Network
Out-of-Network
In-Network
Out-of-Network
Emergency
Plan pays 70% ^
Plan pays 70% ^
Plan pays 70% ^
Care
Urgent Care
Plan pays 70% ^
Plan pays 70% ^
Not Applicable
Outpatient Services
Benefit
In-Network
Out-of-Network
In-Network
Out-of-Network
Hospice
Plan pays 70% ^
Plan pays 50% ^
Plan pays 70% ^
Plan pays 50% ^
Bereavement
Plan pays 70% ^
Plan pays 50% ^
Plan pays 70% ^
Plan pays 50% ^
Counseling
1/1/2017
ASO
KitTrak: CSM11460
4 of 12
Cigna 2016
Benefit

Pregnancy
In-Network
Maternity
Plan pays 70%

^
Out-ofNetwork
Plan pays 50%
^

Delivery Charges)
Out-ofIn-Network
Network
Plan pays 70%
^
Plan pays 50%

^

In-Network
Plan pays 70%
^
Out-ofNetwork
Plan pays 50%
^
Delivery - Facility
Center)
In-Network
Covered same
as plan's
Inpatient
Hospital benefit
Out-ofNetwork
Covered same
as plan's
Inpatient
Hospital benefit
Physician's Office
Benefit
In-Network
Out-ofNetwork
Inpatient Facility
In-Network
Out-ofNetwork
Outpatient Facility
In-Network
Out-ofNetwork
Services
Out-ofIn-Network
Network
Services
Out-ofIn-Network
Network
Abortion
(Elective and
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
70% ^
50% ^
70% ^
50% ^
70% ^
50% ^
70% ^
50% ^
70% ^
50% ^
non-elective
procedures)
Family
Planning Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Men's
70% ^
50% ^
70% ^
50% ^
70% ^
50% ^
70% ^
50% ^
70% ^
50% ^
Services
Family
Planning Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Women's
100%
50% ^
100%
50% ^
100%
50% ^
100%
50% ^
100%
50% ^
Services
Infertility
any other illness.
Bariatric
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Plan pays
Surgery
70% ^
50% ^
70% ^
50% ^
70% ^
50% ^
70% ^
50% ^
70% ^
50% ^
Surgeon Charges Lifetime Maximum: $10,000
1/1/2017
ASO
KitTrak: CSM11460
5 of 12
Cigna 2016
Physician's Office
Inpatient Facility
Outpatient Facility
Benefit
Out-ofOut-ofIn-Network
In-Network
Network
Network
Non-Lifesource
Benefit
Lifesource Facility
Facility
Out-of-Network
In-Network
In-Network
In-Network
Organ
Transplants
Plan pays 100%
Plan pays 70% ^
Plan pays 50% ^
Out-ofNetwork
Services
Out-ofIn-Network
Network
Services
Out-ofIn-Network
Network

Non-Lifesource
Lifesource Facility
Facility
Out-of-Network
In-Network
In-Network
Plan pays 50% ^ up to
the following
transplant maximums:
Plan pays 100%
Plan pays 70% ^
Bone Marrow $130,000

Heart - $150,000
Heart/Lung - $185,000
Kidney - $80,000
Kidney/Pancreas $80,000 Liver $230,000
Lung - $185,000
Pancreas - $50,000

Inpatient
Benefit
In-Network
Out-of-Network
In-Network
Out-of-Network
In-Network
Out-of-Network
Mental Health
Plan pays 70% ^
Plan pays 50% ^
Plan pays 70% ^
Plan pays 50% ^
Plan pays 70% ^
Plan pays 50% ^
Substance Use
Plan pays 70% ^
Plan pays 50% ^
Plan pays 70% ^
Plan pays 50% ^
Plan pays 70% ^
Plan pays 50% ^
Disorder
1/1/2017
ASO
KitTrak: CSM11460
6 of 12
Cigna 2016

Pharmacy
Patient pays the brand coinsurance plus the cost difference
between the brand and generic drugs up to the cost of the brand
drug.
Your pharmacy benefits have a combined annual deductible and
out-of-pocket maximum with the medical/behavioral benefits. The
applicable cost share for covered drugs applies after the combined
deductible has been met.
Mandatory home delivery: Maintenance medications, including
oral contraceptives, must be filled through home delivery;
otherwise after 3 retail fills you pay the entire cost of the
prescription
Delivery
In-Network
Out-of-Network



Home Delivery
Not Covered
1/1/2017
ASO
KitTrak: CSM11460
7 of 12
Cigna 2016

Clinical Programs
o Theracare Program
Case Management
coinsurance.
1/1/2017
ASO
KitTrak: CSM11460
8 of 12
Cigna 2016
Heart Disease
Angina
Lifestyle issues
Asthma
Pre/post-admission
Bronchitis)
Diabetes Type 1
Gaps in care
Diabetes Type 2
Osteoarthritis
Low Back Pain
Anxiety
Bipolar Disorder
Depression
Definitions
1/1/2017
ASO
KitTrak: CSM11460
9 of 12
Cigna 2016
Exclusions
available.
or federal law.
or
Panniculectomy; Rhinoplasty; Blepharoplasty; Acupressure; Craniosacral/cranial therapy; Dance therapy, Movement therapy; Applied kinesiology; Rolfing;
Prolotherapy; and Extracorporeal shock wave lithotripsy (ESWL) for musculoskeletal and orthopedic conditions.
Surgical or nonsurgical treatment of TMJ disorders.
1/1/2017
ASO
KitTrak: CSM11460
10 of 12
Cigna 2016
Exclusions
safety, and services, training, educational therapy or other nonmedical ancillary services for learning disabilities, developmental delays, autism (except as
provided in Short-Term Rehabilitation section of covered services) or mental retardation.
Private Hospital rooms except as provided under the Home Health Services provision.
Artificial aids including, but not limited to, corrective orthopedic shoes, arch supports, elastic stockings, garter belts, corsets, dentures.
1/1/2017
ASO
KitTrak: CSM11460
11 of 12
Cigna 2016
Exclusions
Massage therapy.

EHB State: PA
1/1/2017
ASO
KitTrak: CSM11460
12 of 12
Cigna 2016

Open Access Plus
Coverage Period: 01/01/2017 - 12/31/2017
Important Questions
What is the overall
deductible?
Answers
For in-network providers $2,850 person / $5,700 family
family
immunizations, prescription drugs
No.

on my expenses?
family
No.
Why this Matters:


of providers?


specialist?

doesn't cover?
Yes.
services.

1 of 8

If you have a test

In-Network Provider

30% co-insurance
injury or illness
Specialist visit
30% co-insurance
30% co-insurance for
Other practitioner office visit
chiropractor
No charge
immunization
30% co-insurance
work)
30% co-insurance
MRIs)
50% co-insurance
-----------none-----------
50% co-insurance

50% co-insurance
50% co-insurance
-----------none-----------
50% co-insurance
-----------none-----------
50% co-insurance

2 of 8

Generic drugs

prescription drug
www.myCigna.com

Facility fee (e.g.,
Emergency medical
medical attention
transportation
Urgent care
surgery

In-Network Provider
delivery)
delivery)
delivery)

(home delivery).
limits.
30% co-insurance
50% co-insurance
30% co-insurance
30% co-insurance
50% co-insurance
30% co-insurance

-----------none-----------
30% co-insurance
30% co-insurance
-----------none-----------
30% co-insurance
30% co-insurance
-----------none-----------
30% co-insurance
50% co-insurance
30% co-insurance
50% co-insurance

3 of 8

If you are pregnant
If you need help


In-Network Provider
outpatient services
30% co-insurance
50% co-insurance

inpatient services
30% co-insurance
50% co-insurance
30% co-insurance
50% co-insurance

30% co-insurance
50% co-insurance
30% co-insurance
50% co-insurance
-----------none-----------
30% co-insurance
50% co-insurance

outpatient services
inpatient services
services
Home health care
30% co-insurance
50% co-insurance
30% co-insurance
50% co-insurance
Not Covered
Not Covered
30% co-insurance
50% co-insurance

Hospice services
30% co-insurance
30% co-insurance
50% co-insurance
50% co-insurance


days for Pulmonary rehab and
Cognitive therapy; 60 days for
Physical, Speech & Occupational
therapies; Unlimited days for Cardiac
rehab services
annual max.
4 of 8

or eye care
Eye Exam
Glasses
Dental check-up

In-Network Provider
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered

-----------none---------------------none---------------------none-----------

Cosmetic surgery
Dental care (Adult)
Long-term care
Routine foot care
Eye care (Children)
Acupuncture
Chiropractic care
Hearing aids
Bariatric surgery

5 of 8





Chinese (): 1-800-244-6224.
6 of 8
Coverage Examples
different plans.

these examples.
Having a baby
(normal delivery)
Plan pays: $3,290
Sample care costs:
$2,700
$2,100
$900
Anesthesia
$900
Laboratory tests
$500
Prescriptions
$200
Radiology
$200
$40
Total
$7,540
Patient pays:
Deductible
Co-pays
Co-insurance
Total
$2,850
$0
$1,370
$30
$4,250

condition)
Plan pays: $2,920
Sample care costs:
Prescriptions
$2,900
$1,300
$700
Education
$300
Laboratory tests
$100
$100
Total
$5,400
Patient pays:
Deductible
Co-pays
Co-insurance
Total

$990
$0
$1,210
$280
$2,480
7 of 8


health plan.
have been higher.

limited.

own care needs?

factors.

future expenses?

plans?



expenses.

allows.
Plan Name: $2,850 Deductible HSA Plan
Kit Track: SBM25271

8 of 8
DELTA DENTAL PPO :

YOUR SMILE IS
COVERED
GO PPO!
You can visit any licensed dentist under this plan, but youll
maximize plan value by selecting a Delta Dental PPO1 dentist.
PPO network dentists have agreed to reduced contracted rates
and cant balance bill you for additional fees.2 Find a dentist
at deltadentalins.com.3
CONVENIENT ONLINE SERVICES: DELTADENTALINS.COM
> Create a free Online Services account from your PC or
smartphone to view benefits, eligibility and claims status or
check average dental costs in your area.
> Update your dental benefit statement delivery preference:
Go paperless!
> Find a Delta Dental PPO dentist near you.
NO ID CARD NECESSARY
Just provide your dental office with your name, birth date
and enrollee ID or social security number. Register for Online
Services to print an ID card or pull it up on your smartphone at
the dentists office.
HASSLE-FREE TRANSITION & EASY BENEFITS COORDINATION
New to Delta Dental PPO? This plan covers treatment started
and completed after your plans effective date of coverage.4
If youre covered under two plans, ask your dentist to include
information about both plans with your claim, and well handle
the rest.
SAVE WITH A
PPO DENTIST
DELTA DENTAL PPO
NON-DELTA
DENTAL DENTISTS
In Texas, Delta Dental Insurance Company offers a Dental Provider Organization (DPO) plan.
Enrollees are responsible for any coinsurance, deductible, amount over the plan maximum and charges for non-covered services.
Verify that your dentist is a contracted Delta Dental PPO network dentist before each appointment.
Applies only to procedures covered under your plan. If you began treatment prior to your effective date of coverage, you or your prior carrier will be responsible for any costs. Group- and statespecific exceptions may apply. Enrollees currently undergoing active orthodontic treatment may be eligible to continue treatment under Delta Dental PPO. Review your Evidence of Coverage,
Summary Plan Description or Group Dental Service Contract for specific details about your plan.
HL_PPO_2 col #78011
LEGAL NOTICES: Access federal and state legal notices related to your plan: deltadentalins.com/about/legal/index-enrollee.html
Plan Benefit Highlights for: Management Science Associates

Group No: 16825
Effective Date: 1/1/2015
Eligibility
Primary enrollee, spouse and eligible dependent children to the end of the
month that dependent turns age 19 or to the end of the month dependent
turns age 25 if dependent is full-time student
Deductibles
$50 per person / $150 per family each calendar year
Deductibles waived for Diagnostic &

Preventive (D & P)?
Maximums
D & P counts toward maximum?
Waiting Period(s)
Yes
$2,000 per person each calendar year
Yes
Basic Benefits
None
Major Benefits
None
Prosthodontics
None
Orthodontics
None
Benefits and
Covered Services*
Delta Dental PPO

dentists**
Non-Delta Dental PPO

dentists**
Diagnostic & Preventive

Services
100 %
100 %
80 %
80 %
80 %
80 %
80 %
80 %
50 %
50 %
50 %
50 %
50 %
50 %
50 %
50 %
$1,500 Lifetime
$1,500 Lifetime
Exams, cleanings, x-rays and

sealants
Basic Services
Fillings, space maintainers, simple
extractions, surgical removal of
erupted tooth, denture repairs and
posterior composites
Endodontics (root canals)

Covered Under Basic Services
Periodontics (gum treatment)

Covered Under Basic Services
Removal of Impacted Teeth

General anesthesia/IV Sedation
Major Services
Crowns, inlays, onlays, cast
restorations and TMJ
Prosthodontics
Bridges, dentures and implants
Orthodontic Benefits
Dependent children to age 19
Orthodontic Maximums
*
Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan.
Reimbursement is based on Delta Dental maximum contract allowances and not necessarily each dentists
submitted fees.
** Reimbursement is based on PPO contracted fees for PPO dentists, Premier contracted fees for Premier
dentists and 80th percentile for non-Delta Dental dentists.
Delta Dental of Pennsylvania

One Delta Drive
Mechanicsburg, PA 17055
Customer Service
Claims Address
800-932-0783
P.O. Box 2105

Mechanicsburg, PA 17055-6999
deltadentalins.com
This benefit information is not intended or designed to replace or serve as the plans Evidence of Coverage or
Summary Plan Description. If you have specific questions regarding the benefits, limitations or exclusions for your
plan, please consult your companys benefits representative.
HLT_PPO_2COL_DDP (Rev. 10/07/2014)
Keep your eyes healthy with

Management Science Associates
and VSP Vision Care.
Why enroll in VSP? Your eyes deserve the best care to
keep them healthy year after year. Plus with VSP, youll
get a great value on your eyecare and eyewear.
Youll like what you see with VSP.

Value and Savings. You'll get great benets on your exam and
eyewear at an affordable price.
Personalized Care. Youll get quality care that focuses on your eyes
and overall wellness with VSP. Plus, your satisfaction is guaranteed
when you see a VSP doctor.
Great Eyewear. Choose the eyewear thats right for you and
your budget.
Choice of Providers. You can choose any eyecare provideryour
local VSP doctor, a retail chain afliate, or any other provider. Once
your benet is effective, visit vsp.com for your complete benet
description.
Using your VSP benet is easy.

Find an eyecare provider whos right for you.
To nd a VSP doctor or retail chain afliate, visit vsp.com or call
800.877.7195.
Review your benet information.
Visit vsp.com to review your plan coverage before your appointment.
At your appointment, tell them you have VSP.
Theres no ID card necessary.
Thats it! Well handle the restthere are no claim forms to complete
when you see a VSP doctor or retail chain afliate.
Choice in Eyewear
From classic styles to the latest designer frames, youll nd hundreds of
options for you and your family. Choose from great brands, like bebe,
Calvin Klein, Disney, FENDI, Nike, and Tommy Bahama.
Enroll in VSP today.

You'll be glad you did.
Contact us.
vsp.com
800.877.7195
Your VSP Vision Benets Summary

Management Science Associates and VSP provide you with an affordable eyecare plan.
VSP Doctor Network: VSP Choice
Benefit
Visit vsp.com for more details on your

vision benet and for exclusive savings
and promotions for VSP members.
Description
Copay
Frequency
Your Coverage with VSP Doctors and Afliate Providers*

WellVision Exam
Focuses on your eyes and overall wellness
Prescription Glasses
$10
Every 12 months
$25
See frame and lenses
Frame
$130 allowance for a wide selection of frames

20% off amount over your allowance
You have a $70 allowance at Costco Optical
Included in
Prescription
Glasses
Every 24 months
Lenses
Single vision, lined bifocal, and lined trifocal lenses

Polycarbonate lenses for dependent children
Included in
Prescription
Glasses
Every 12 months
Lens Options
Contacts
(instead of glasses)
$130 allowance for contacts; copay does not apply

Contact lens exam (tting and evaluation) covered in full with $60
copay
Standard progressive lenses

Premium progressive lenses
Custom progressive lenses
Average 20-25% off other lens options
$55
$95 - $105
$150 - $175
Every 12 months
Every 12 months
Save with VSP coverage:

Extra Savings
and Discounts
Glasses and Sunglasses

20% off additional glasses and sunglasses, including lens options, from any VSP doctor within 12 months of your
last WellVision Exam.
Laser Vision Correction
Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities
Your Coverage with Other Providers
Visit vsp.com for details, if you plan to see a provider other than a VSP doctor.
Exam............................................up to $45
Frame..........................................up to $70
Single Vision Lenses............up to $30

Lined Bifocal Lenses...........up to $50
Lined Trifocal Lenses..........up to $65

Progressive Lenses..............up to $50
Contacts....................................up to $105
*Coverage with a retail chain afliate may be different. Once your benet is effective, visit vsp.com for details.
Coverage information is subject to change. In the event of a conict between this information and your organizations contract with VSP, the terms of the contract will prevail.
Enroll in VSP today.

You'll be glad you did.
Contact us. vsp.com
800.877.7195
2010 Vision Service Plan. All rights reserved.

VSP and WellVision Exam are registered trademarks of Vision
Service Plan. All other company names and brands are
trademarks or registered trademarks of their respective owners.

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SUMMARY OF BENEFITS

Cigna Health and Life Insurance Co.

$40 Primary Care Physician (PCP) copay

Your plan pays 60% ^

Your plan pays 80% ^

Your plan pays 60% ^

Your plan pays 80% ^

Your plan pays 60% ^

$40 PCP or $80 Specialist copay

Your plan pays 60% ^

Calendar Year Maximums:

Other Health Care Facilities/Services

Your plan pays 80% ^

Your plan pays 60% ^

Your plan pays 80% ^

Your plan pays 60% ^

Your plan pays 80% ^

Your plan pays 60% ^

Your plan pays 100%

Your plan pays 60% ^

Your plan pays 80% ^

Your plan pays 60% ^

Lab and XPlan pays 80%

Initial Visit to Confirm

$40 PCP or $80

Global Maternity Fee

Plan pays 60%

Office Visits in Addition to

Plan pays 60%

Mental Health and Substance Use Disorder Services

Cigna Pharmacy three-tier coinsurance plan

Retail - 30 day supply

Home Delivery - 90 day supply

Pharmacy Program Information

Pharmacy Program Information

Holistic health support for the following chronic health conditions:

plan because treatment was received from a nonparticipating provider.

These are only the highlights

Management Science Associates, Inc. Exchange Account:

Coverage Period: 01/01/2017 - 12/31/2017

Yes. For in-network providers $2,400 person / $4,800

Yes. For a list of participating providers, see

Do I need a referral to see a

No. You don't need a referral to see a specialist.

Why this Matters:

Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com.

Are there services this plan

Why this Matters:

Common Medical Event

If you visit a health care

If you have a test

Services You May Need

Your Cost if you use an

Primary care visit to treat an

-----------none----------Coverage for Chiropractic care is

Limitations & Exceptions

50% penalty for no precertification.

Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com.

Common Medical Event