Under the Indemnity Plan, you may receive care from any provider you choose. After you meet your annual deductible, the plan pays 80% of Reasonable and Customary Charges for medically necessary services and supplies until you reach the annual out-of-pocket maximum.

The out-of-pocket maximum protects you from excessive medical costs by establishing a ceiling on the amount you pay for covered medical expenses during a year. Once you reach the out-of-pocket maximum, the plan pays 100% of Reasonable and Customary Charges for eligible medical expenses for the rest of that year.

You must file claims to be reimbursed for your eligible expenses. Claim forms are available from the Benefit Plans Office or CIGNA Member Services.

You must also call CIGNA Member Services to precertify any nonemergency hospitalization or outpatient diagnostic test or procedure. If you do not call, your benefit will be subject to a penalty.

Reasonable and Customary Charges
All Indemnity Plan benefit payments are subject to Reasonable and Customary Charges. Any charges above Reasonable and Customary Charges are not covered by the plan, and you will not be reimbursed for them. Also, these amounts will not count toward the deductible or out-of-pocket maximum.

See the Glossary for a definition of "Reasonable and Customary Charge."

The Family Deductible
Although the deductible applies separately to each covered family member, the plan contains a provision called the family deductible that limits the total amount you pay in deductibles each year.

You can meet the family deductible with any combination of individual expenses. However, once one family member meets his or her individual deductible, any further expenses incurred by that person may not be applied to the family deductible. Once the family deductible is met, no other family member needs to meet the deductible for that year.

The Out-of-Pocket Maximum
The out-of-pocket maximum limits the amount you pay for medical expenses in one year.

Once you reach the out-of-pocket maximum, the plan pays 100% of covered expenses. Certain expenses do not count toward the out-of-pocket maximum:

• expenses for substance abuse treatment
• non-compliance penalties for not following precertification requirements
• charges above Reasonable and Customary Charges
• care that is received but not covered by the plan.

Second Surgical Opinion
Second surgical opinions are not mandatory, but are covered by the plan with certain limitations. If your physician recommends surgery, the plan pays 100% of the Reasonable and Customary Charge for a second surgical opinion, with no deductible. If additional opinions are necessary, they will be covered at 80% of Reasonable and Customary Charges.

Preadmission and Post-Confinement Testing
The plan pays 100% of the cost of preadmission and post-release testing performed on an outpatient basis within 14 days before a scheduled admission, or within 14 days after you leave the hospital, provided the testing is related to your surgery. If the preadmission tests are performed and your admission is later cancelled, or if the tests are duplicated while you are in the hospital, the plan will pay 80% of Reasonable and Customary Charges for the tests, after you meet the deductible.

Mental Health/Alcohol and Substance Abuse Treatment
After you meet the deductible, the Indemnity Plan pays 80% of Reasonable and Customary Charges for mental health/alcohol and drug abuse treatment, up to the limits described in the chart on the following pages. Inpatient care must be precertified by contacting the mental health/substance abuse (MH/SA) number shown on your ID card.

CIGNA Indemnity Plan
Annual Deductible Amount for injury, illness or maternity	0.5% of pay / individual (minimum $200) 1.50% of pay / family (minimum $400)
Out-of-Pocket Annual Limit (includes deductible)	3% of pay / individual (minimum $2,000) 6% of pay / family (minimum $4,000)
Pre-Existing Conditions	n/a
Maximum Lifetime Benefit	$2,000,000
Annual Reinstatement	$5,000
Hospital Care
Services	Coverage
Inpatient Services: semi-private room, operating room, X-ray, and laboratory services	Covered 80% of R&C* after deductible
Outpatient Services: Outpatient surgery Outpatient professional services – surgeon, radiologist, pathologist, anesthesiologist X-ray and laboratory services	Covered 80% of R&C* after deductible
Organ Transplant Coverage	Covered 80% of R&C* after deductible Travel services maximum when transplant procedure is performed at a LifeSource Facility: $10,000 per transplant
Emergency Room	Covered 80% of R&C* after deductible
Inpatient Mental Health	Covered 80% of R&C* after deductible, limit 20 inpatient days per calendar year
Inpatient Substance Abuse	Covered 80% of R&C* after deductible, limit 30 inpatient days per year and 60 days per lifetime
Maternity – Inpatient	Covered 80% of R&C* after deductible
Inpatient services at other health care facilities: Includes Skilled Nursing Facility, Rehabilitation Hospital and Subacute Facilities	Covered 100% of R&C*  Up to 60 days confinement per calendar year maximum
Ambulance Services	Covered 80% of R&C* after deductible
Outpatient Short-Term Rehabilitation Includes cardiac, physical, speech, and occupational therapy Contract year maximum is unlimited	Covered 80% of R&C* after deductible
Physician Care
Services	Coverage
Physician Office Visit Surgery performed in the physician’s office Allergy Treatment/Injections Maternity office visits	Covered 80% of R&C* after deductible
Vision Exam Services Provided by VSP	In-Network: No charge for yearly exam; no charge for standard frames every 24 months; no charge for standard lenses every 12 months; or reimbursement up to $75 for one pair of contact lenses (replaces all other benefits and includes exam) Out-of-Network: Plan covers up to $25 toward yearly exam; up to $40 toward pair of frames every 24 months; lenses according to fee schedule or one pair of contact lenses every 12 months up to $75 (replaces all other benefits and includes exam)
Chiropractic Care	Covered 80% of R&C* after deductible 25 visit limit per year
Emergency Care at Doctor's Office	Covered 100% of R&C*
Urgent Care Facility	Covered 80% of R&C* after deductible
Physician and Surgeon Services in Hospital	Covered 80% of R&C* after deductible
Allergy Serum (dispensed by the physician in the office)	Covered 80% no deductible
Maternity Delivery (physician charges)	Covered 80% of R&C* after deductible
Preventive Health Services: Well-child care for children to age 3 (including immunizations) Annual routine physicals, adult immunizations, Well Woman care ($500 includes all adult preventive care) Mammogram, pap test, or Prostate Specific Antigen Test (PSA)	Covered 80% of R&C* after deductible
Hearing Aid Benefits	Not Covered
Laboratory and X-ray MRIs, MRAs, CAT Scans and PET scans	Covered 80% of R&C* after deductible
Home Health Care (skilled visits only) Maximum number of hours per day is limited to 16 hours. Multiple visits can occur in one day; with a visit defined as a period of 2 hours or less.	Covered 100% of R&C*, no deductible Up to 60 days per calendar year maximum
Hospice Care	Inpatient services covered 80% of R&C*, maximum 60 days per lifetime. Inpatient room and board at the semi-private room rate Outpatient services same as Home Health Care benefit Bereavement Counseling covered 80% after the deductible, maximum $100 per occurrence; visits subject to the Plan’s outpatient mental health limit
Substance Abuse	Outpatient covered 80% of R&C* after deductible, 30 visit limit per year Group therapy covered 80% of R&C* after deductible, subject to the plan’s Outpatient Substance Abuse benefit maximum based on a 2:1 ratio (visits used reduce the number of substance abuse outpatient visits available.)
Mental Health Service	Outpatient covered 80% of R&C* after deductible, 30 visit limit per year Group therapy covered 80% of R&C* after deductible, subject to the plan’s Outpatient Mental Health benefit maximum based on a 2:1 ratio (visits used reduce the number of mental health outpatient visits available.)
Physician Services in Emergency Room	Covered 80% of R&C* after deductible
Durable Medical Equipment	Covered 80% of R&C* after deductible
Infertility Treatment	Limited coverage Artificial insemination lifetime maximum: 3 attempts per menstrual cycle with a maximum of 8 cycles per lifetime (total attempts allowed is 24) Invitro fertilization, GIFT and ZIFT lifetime maximums: 4 attempts
External Prosthetic Devices – Requires approval by Health Plan	Covered 80% of R&C* after deductible
Dental Care – Limited to charges for a continuous course of dental treatment started within six months of an injury to sound, natural teeth	Inpatient and outpatient facility benefit and physicians services covered 80% after the deductible
Temporomandibular Joint Disorder (surgical & non-surgical treatment)	Covered 80% of R&C* after deductible
Chemotherapy & Radiotherapy	Inpatient services 80% of R&C* after deductible Outpatient services covered 100% of R&C
Prescription Drugs, administered by Medco
	In-Network	Out-of-Network*
Retail Prescription Drugs (Up to a 30-day supply)	$150 deductible Generic: 20% (minimum $10 copayment) after deductible Brand: 30% (minimum $10 copayment) after deductible If actual cost is under $10, then you pay actual cost	50% of cost after $150 deductible
Mail Order – Home Delivery (Up to a 90-day supply)	Generic: $15 copayment up to a 90-day supply Brand: $35 copayment up to a 90-day supply	Not covered

*R&C — Reasonable and Customary Charges