Product Disclosures

The products and services described on our websites may not be applicable to you or available to you under your plan. Please refer to your policy or plan documents for information that is applicable to your specific plan.

We recommend reading any disclosure that's applicable to you before purchasing a Cigna Healthcare insurance policy or enrolling in a Cigna Healthcare-administered plan so that you can become more familiar with your plan and any state-specific mandates. If you are considering a plan through Cigna Healthcare or have questions about your plan coverage, please contact your licensed insurance agent or a Cigna Healthcare representative.

While reviewing the information on this page, it's important to note:

The disclosures provided here are general and your policy, service agreement or plan documents may contain additional disclosures which are required by your state and/or specific to your plan. The disclosures in your policy, service agreement or plan documents take precedence.
Certain mandates may only apply to certain policies or plan types.
State mandates may not apply to employer-funded (or self-insured) group plans. Please contact your plan sponsor if you need to know whether your plan is self-insured and whether any state mandates apply to your plan.

Product details for Cigna Healthcare Individual and Family Medical and Dental plans may vary by state. Before applying for insurance coverage, be sure to read the policy/service agreement information and disclosures applicable to your specific state and policy/service agreement. To find information related to your state, visit https://www.cigna.com/individuals-families/shop-plans/health-insurance-plans.

All insurance policies, service agreements and group benefit plans may have exclusions, limitations, reduction of benefits and terms under which the policy may be continued in force or discontinued. Rates may vary and are subject to change. Health coverage is provided subject to any deductibles, co-payment, or coinsurance provisions. For costs and a complete list of both covered and not-covered services under your plan, policy or service agreement, including benefits required by your state, see your insurance policy, service agreement, evidence of coverage, or your employer’s insurance certificate or summary plan description.

Understanding Your Cost-Sharing Responsibilities

Be sure to be aware of your cost-sharing obligations when seeking care. The Notice Regarding Waiver of Cost Sharing Amounts explains important details about in-network and out-of-network costs including copayments, deductibles, coinsurance, and balance bills.

For Providers: Notice Regarding Waiver of Cost Sharing Amounts [PDF]

The product descriptions, if any, provided on Cigna Healthcare websites are for informational purposes only and are subject to change. Product availability may vary by area and plan type and is subject to change. Product descriptions are not a contract and are not intended to constitute offers to sell or solicitations in connection with any products or services. Anyone interested in a particular product should contact their licensed insurance agent, Cigna Healthcare sales representative or plan sponsor to determine whether the product is available in their area and to request a copy of the applicable policy, service agreement, or other plan documents for a complete description of the product.

Cigna Healthcare makes available sample group policy forms to help our current and prospective customers understand the services which may or may not be covered under the different health plans we insure and/or administer.

To help you make an informed choice, sample medical booklet documents are available for your review:

Sample Booklets

* Cigna Open Access Plus Plan

* Cigna Comprehensive Plan

* Cigna Exclusive Provider Plan

* Cigna LocalPlus Plan

* Cigna Preferred Provider Plan

* Cigna HealthCare HMO-Open Access Plan

* Cigna HealthCare Point of Service Plan

*These forms are for illustrative purposes only and the terms of your specific group policy or plan may vary. No benefits are guaranteed. These forms are not legal documents or contracts and no coverage representation is considered to be actual medical benefits provided to you by Cigna Healthcare. If there are any differences between the information in these sample forms and the terms of your official plan documents, the terms of your official plan documents will apply.

The following Cigna Healthcare health plan document is available for your review. This document offers an explanation of our process for ensuring that non-quantitative treatment limitations (NQTLs) comply with the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA).

Non-Quantitative Treatment Limitations (NQTL) Summary [PDF]

Topic Specific Information

This is a standard policy document. No benefits are guaranteed. No coverage representation is considered to be actual medical benefits provided to you by Cigna Healthcare. If you want more details about your coverage, visit myCigna.com.

Patient experience, quality designations, cost-efficiency and other ratings found in our online provider directories reflect a partial assessment of quality and/or cost and should not be the sole basis for decision-making (as such measures have a risk of error). They are not a guarantee of the quality of care that will be provided to individual patients. Individuals are encouraged to consider all relevant factors and consult with their physician when selecting a health care provider. Health care providers that participate in the Cigna Healthcare network are independent contractors solely responsible for the treatment provided to their patients. They are not agents of Cigna Healthcare. Actual costs will vary depending on the location and type of services received. Your plan deductible, co-payment and coinsurance requirements apply and may vary based on the type of facility and health care professional providing care. The listing of a health care professional or facility in the network directory does not guarantee that the services rendered by that professional or facility are covered under your specific policy or medical plan. Check your policy or official plan documents for complete details about costs and the services covered under your plan benefits.

The CignaPlus Savings program is NOT insurance, and the member must pay the entire discounted charge.

The CignaPlus Savings^®dental discount program provides customers access to discounted fees, pursuant to schedules negotiated by Cigna Healthcare Dental with participating providers, which customers are responsible for paying in full, directly to participating providers. Although all participating providers go through a credentialing process to assure that they are appropriately licensed and qualified, Cigna Healthcare Dental does not otherwise guarantee nor is it responsible for the quality of any services or products purchased by customers. Customers have the right to cancel within thirty (30) calendar days of enrolling in the program. For more information, please call or write Cigna Healthcare Dental:

Cigna Healthcare Dental
Attn: Operations
1571 Sawgrass Corporate
Parkway, Suite 140
Sunrise, FL 33323
Telephone: 1 (877) 521-0244

HRAs can only be chosen together with certain plan types. Your HRA is self-funded by your employer, who is solely responsible for contributing the funds used to pay benefits under your plan using the funds in your HRA. You are not required to make any contribution to the HRA account, either pursuant to a salary deduction election or otherwise under a Section 125 cafeteria plan. You may not enroll under this option if you are considered self-employed (including partners and more-than-2% shareholders in a subchapter S corporation).

You cannot open an HSA if, in addition to coverage under an HSA-qualified High Deductible Health Plan ("HDHP"), you are also covered under a Health Flexible Spending Account (FSA) or an HRA or any other health coverage that is not a HDHP.

If you have elected to enroll in an HSA plan, you expressed your interest in opening a Health Savings Account with an HSA service provider. The HSA service provider you choose will contact you and provide you with an HSA enrollment form, a signature card, a request for information for any Customer Identification Program compliance and other related materials necessary to open an HSA account with the HSA service provider. In order to open an HSA with the HSA service provider, you must:

In a timely manner, complete, sign and submit all the forms required by the HSA service provider; and
Be found to meet all of the requirements prescribed by the HSA service provider.

If you are enrolled in a Cigna Healthcare Individual and Family Health Savings Plan, you will need to contact the HSA service provider of your choice to set up a Health Savings Account to pair with your Cigna Healthcare Health Savings Plan.

If you are offered a Cigna Healthcare-administered HDHP through your employer and your employer has not selected the Cigna Healthcare-preferred HSA service provider, you may open the HSA with an HSA custodian/trustee that is either arranged by your employer or that you personally select. You must agree to complete necessary forms and meet the requirements set forth by the HSA custodian/trustee pertaining to the establishment and operation of your HSA.

The HSA provider and/or trustee/custodian will be solely responsible for all HSA services, transactions and activities related thereto. Cigna Healthcare is not responsible for any aspects of the HSA services, administration and operation.

Prior to enrollment with an HSA provider, you must certify that you have enrolled or plan to enroll under a HDHP and are not covered under any other health coverage that is not a HDHP.

Provider Specific Information

A health care provider that doesn't participate in a Cigna Healthcare network is considered out-of-network. Cigna Healthcare has a number of different networks and a health care provider that participates in one network may not participate in all. Because out-of-network providers do not have contracted rates, Cigna Healthcare can use multiple techniques to calculate the reimbursement amount for covered services.

Third-Party Partners

Cigna Healthcare may work with third party partners that attempt to establish an agreed upon price for services provided by out-of-network health care provides, while also protecting customers from surprise balance billing. These programs include:

Multiplan (Network Savings Program/NSP)

If the MultiPlan Savings Program logo appears on the customer’s ID card, the provider may be eligible to apply the MultiPlan discount. Per the contract, discounts are not guaranteed. When this discount is applied, providers should not balance bill the customer for any amounts other than their out-of-network cost-sharing responsibility.
Bill Negotiation Services (BNS).

A suite of other services could also be used to attempt to calculate the reimbursement amount for covered services provided by out-of-network healthcare providers. This might include pricing using other supplemental networks, or direct negotiations with the health care provider. It may also include a technique called repricing that offers the out-of-network health care provider an amount based on a market-based rate as payment in full for the services (minus any out-of-network cost-sharing that the customer may owe). Providers that accept amounts offered through bill negotiation services should not balance bill the customer for any amounts other than their out-of-network cost-sharing responsibility. When a claim is processed using repricing, the customer’s EOB will provide the contact information for the third-party vendor that Cigna Healthcare partnered with to reprice that claim, instructing the provider to contact the vendor before balance billing the customer.

Maximum Reimbursable Charge (MRC)

The MRC represents the maximum amount that Cigna Healthcare will pay an out-of-network health care provider for a covered service under the medical plan absent resolution through the NSP or BNS.

Many of the group health insurance policies and employee health benefit plans that Cigna Healthcare administers cover expenses incurred for services from health care professionals or facilities who do not participate in the Cigna Healthcare professional network. Those policies and plans include Maximum Reimbursable Charge ("MRC") provisions that may limit the amount of an out-of-network charge that will be considered by Cigna Healthcare in calculating reimbursement. The plan sponsor (your employer or other organization) may choose one of the following MRC provisions which apply absent an agreed upon amount with the health care professional or facility:

MRC1

Under this option, Cigna Healthcare selects a third-party database that compiles billed charges made by health care professionals or facilities in a geographic area for the same procedure codes. The maximum reimbursable amount is then determined by applying a percentile (often the 70th or 80th percentile) of the billed charges reflected in the selected database. For example, if the plan sponsor has selected the 80th percentile, then any portion of a charge that is in excess of the 80th percentile of charges billed for the particular service in the geographic area (as determined using the third-party data) will not be considered in determining reimbursement and the patient will be fully responsible for such excess. The database that Cigna Healthcare selects for determining MRC1 may differ based on the type of service or supply at issue and may also utilize data at the state, regional or national level, or for similar services, if sufficient data at the local level for the service is unavailable.

MRC2

This option uses a schedule of charges established using a methodology similar to that used by Medicare to determine allowable fees for services within a geographic market or at a particular facility. The schedule amount is then multiplied by a percentage (i.e. 110%, 150% or 200%) selected by the plan sponsor to produce the MRC amount.

In some cases where Cigna Healthcare cannot apply a MRC2 rate, the MRC amount is determined based on the lesser of:

the health care professional or facility's normal charge for a similar service or supply; or
the MRC1 methodology described above, based on the 80th percentile of billed charges.

Please consult your plan document for additional information on how MRC is calculated. Absent an agreed upon amount with the health care professional or facility, under MRC1 or MRC2 the customer is responsible for all charges over the MRC amount, as well as any applicable deductible and coinsurance amounts for charges that do not exceed the MRC. The claim is also subject to all other exclusions and limitations in the applicable benefit plan.

If you are enrolled in a Cigna Healthcare-administered plan, you and your authorized representatives can find the MRC for a particular procedure and geographic location by calling the 800 number on your ID card.

If you use a health care professional who is not in the Cigna Healthcare network, be sure to check your plan documents to make sure that your plan covers out-of-network services. If you have a Flexible Spending Account, you may be able to use that money for out-of-network services.

Cigna Healthcare Secure Travel is provided under a contract with Generali Global Assistance (GGA). GGA and Cigna Healthcare do not guarantee the quality of any medical services provider or medical facility. The final selection of a local medical provider or facility is the covered person’s right and responsibility. The medical professionals or attorneys suggested or designated by GGA are solely responsible for their services. They are not employees or agents of GGA or Cigna Healthcare. Emergency Assistance services may be insured under a group or blanket insurance policy issued by Life Insurance Company of North America or Cigna Life Insurance Company of New York. All other Cigna Healthcare Secure Travel services are NOT insurance and do not provide reimbursement of expenses or financial losses. Expenses for medical care are not covered. In any case where benefits are provided through insurance, the terms of the insurance policy control. All other services are provided by GGA and are subject to the terms of the service agreement with GGA.

The Cignassurance^® Program for beneficiaries is available to beneficiaries receiving coverage checks over $5,000 from Cigna Group Life and Personal Accident Programs. Phone and face-to-face counseling sessions must be used within one year of the date the claim is approved. Cignassurance accounts are not deposit account programs and are not insured by the Federal Deposit Insurance Corporation or any other federal agency. Account balances are the liability of the insurance company and the insurance company reserves the right to reduce account balances for any payment made in error. Counseling, legal or financial assistance programs are not available under policies insured by Cigna Life Insurance Company of New York.

Compensation is paid by Cigna Healthcare to third-party “brokers,” “benefits advisors” and consultants. In the case of individual insurance, this compensation is determined by agreement between Cigna Healthcare and the third party broker. In the case of insured or self-funded group plans, this compensation is determined by agreement of the plan sponsor and its broker or benefits advisor. Cigna Healthcare may bill the client and collect the compensation on behalf of the broker/benefits consultant. This compensation is typically in the form of a percentage of premiums collected (in the case of insurance policies), or a fixed, per-employee per-month rate in the case of self-insured plans.

Additional compensation may be paid by Cigna Healthcare to brokers/benefits advisors based on persistency or other non-case-specific factors. Cigna Healthcare sends reports to group insurance policyholders annually regarding the commission and other compensation paid to brokers/benefit advisors during the prior calendar year for their use in preparing their Annual Return and Report (Form 5500) where required under federal law (ERISA). Upon request, we will also disclose how the Client may receive more information directly from the broker/benefits advisor regarding compensation arrangements.

The primary compensation received with respect to insurance policies is the policyholder paid insurance premium. The primary source of revenue in connection with administrative services contracts is the service fees paid by the self-insured plan sponsor and/or the plan.

In addition to the premium charged to policyholders and the administrative fees charged to sponsors of self-insured group plans, Cigna Healthcare negotiates for compensation from some third-party vendors with which Cigna Healthcare contracts to perform services in connection with the plans we insure or administer. This compensation is to reimburse Cigna Healthcare for its costs of implementing and maintaining programs offered by these third-party vendors. This allows Cigna Healthcare to offer lower premiums and administrative fees.

Cigna Healthcare may subcontract with a third-party vendor for the performance of a service that Cigna Healthcare has agreed to provide to a plan sponsor. The amount charged to the Client for the program or services may include both the vendor’s reimbursement as well as a Cigna Healthcare charge. For example, where Cigna Healthcare contracts with a third-party for the administration of a disease management program, the plan sponsor may be charged both the reimbursement owed the third-party vendor and an additional amount by Cigna Healthcare. Cigna Healthcare may also receive compensation from vendors for placing the business with the vendor. These may be calculated on a per-member per-month (PMPM) basis, flat rate, or on a percentage basis. Cigna Healthcare may receive performance guarantee payments if a vendor does not meet performance targets. Cigna Healthcare may receive other compensation from its third-party vendors. These charges are typically reflected in our agreement with the plan sponsor or in related disclosure documentation.

Cigna Healthcare may receive payments directly from drug manufacturers or Pharmacy Benefit managers with which it contracts. These payments may be consideration for placement of a manufacturer’s drug on the Cigna Healthcare drug formulary.

Cigna Healthcare uses specialized vendors to negotiate discounts for out-of-network claims. The amount charged to self-insured plans reflects the negotiated discount. An administrative fee is paid to the vendor for successfully negotiating a discount under these programs and Cigna Healthcare charges a percentage of the net savings for administering these programs.

When a third party should have been responsible for the claims incurred by a covered individual (as a result of an automobile accident, for example), after paying the claim, Cigna Healthcare may try to obtain reimbursement from the third party responsible for the accident, or that party’s liability insurer. Cigna Healthcare currently pursues reimbursement using a specialized subrogation vendor. For successful efforts, a percentage of the recovery is retained by the vendor and Cigna Healthcare. Additionally, Cigna Healthcare reserves a priority right to reimbursement of any prior stop-loss insurance payments it may have made to Clients.

Certain Cigna Healthcare companies directly provide or arrange for the provision of covered health care services including, but not limited to Evernorth^® Behavioral Health, Inc. and Cigna HealthCare of Arizona, Inc. Their charges for providing or arranging for these services are reimbursed as claims.

Federal and State-Specific Notices and Disclosures

Your Rights and Protections against Surprise Medical Bills
When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center in the United States, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider in the United States, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. You may have additional costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your plan’s deductible or annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in- network facility but are unexpectedly treated by an out-of-network provider. This could happen when you need anesthesia during a surgery. The surgeon may be in-network, but the anesthesiologist may be out-of-network.

Surprise medical bills could cost thousands of dollars depending on the procedure or service.

You’re protected from balance billing for:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of- network provider or facility in the United States the most they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

A state balance billing law may also apply to your health plan. For more information about these protections, please refer to your state specific information on this page.

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center in the United States certain providers there may be out-of-network. In these cases, the most those providers can bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other types of services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

You’re never required to give up your protections from balance billing. You also aren’t required to get out-of-network care. You can choose a provider or facility in your plan’s network.

A state balance billing law may also apply to your health plan. For more information about these protections, please refer to your state specific information on this page.

When balance billing isn’t allowed, you also have these protections in the United States:

You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.
Generally, your health plan must:
- Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”).
- Cover emergency services by out-of-network providers.
- Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
- Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.

If you think you’ve been wrongly billed,

Please call Cigna Healthcare if you get a balance bill. Use the phone number on your ID card. You can also contact the No Surprises Help Desk at 1-800-985-3059 or http://www.cms.gov/nosurprises for more information about your rights under federal law.

A state balance billing law may also apply to your health plan. For more information about these protections, please refer to your state specific information on this page.

For Cigna Global Health Benefits^® customers, the federal requirements only apply to plans underwritten by Cigna Health and Life Insurance Company. For all other plans underwritten outside the United States, the federal requirements specified above do not apply. If you are unsure if the federal requirements apply to your plan, please call Cigna Healthcare. Use the phone number on your ID card.

Transparency in Coverage

I. Important information about your cost estimate

Cost estimates, available on myCigna.com or through Cigna Healthcare Customer Service, give you an idea of the expected cost of a health care item or service before you get care. (Office visits, procedures, medical equipment, and treatments are some examples of items and services.) Please be aware that cost estimates have limits. Consider these limits before you decide to get the item or service:

Estimated costs are as of the date of the estimate. Estimates include several factors, such as how much of your deductible or out-of-pocket maximum you’ve met. Those numbers can change from day to day, so your actual costs may be different, depending on when you have the service.
Actual charges may be higher than the estimate. That could happen if you receive services during your visit than were not included in the estimate. Before and during your visit, ask your provider to confirm which items and services you will receive. Ask for a new cost estimate, if they have changed.
This estimate is not a guarantee that the item or service is covered by your health plan. Some services must be approved by your plan before you receive them. Go to myCigna.com to find a list of services that must be pre-approved. You can also call Customer Service at the toll-free number on your ID card.
Costs have been decided based on your specific health plan and where you are in meeting your deductible and out-of-pocket maximum as of the date of this estimate. Your health plan does not include copayment help and other third-party payments when calculating how much of your deductible or out-of-pocket maximum you’ve met.
The estimate may not tell you when in-network preventive care items or services are covered at 100 percent.
“Balance bills” may not be included in your estimate. If you go to an out-of-network provider, the provider could charge you more than your health plan covers for the service. Then, send you a bill for the difference. This is called balance billing. To avoid balance billing, go to an in-network provider.

II. Prerequisites

Prior Authorization: Some procedures, treatments, or services must be approved before you have them to be covered by your health plan or to avoid extra charges. This process is called prior authorization. Go to myCigna.com for more information on the prior authorization process and a list of services that commonly need preapproval. You also can call the number on your ID card to speak with a Customer Service Associate 24/7/365.
Concurrent Review: Your health plan may require a review during a course of treatment to determine whether the plan will continue to cover it. This is called concurrent or ongoing review. The review must happen within a specific time after starting the treatment. If your provider does not submit the treatment plan for concurrent review, your health plan may stop covering it.
Step Therapy: Your health plan may not pay for higher-cost therapies without evidence that certain lower-cost therapies have not worked for you. This is called step-therapy. That means you may have to try a lower-cost therapy before your plan will cover this particular item or service.

III. What if I need more information?

For more information on your cost estimate or the cost estimator tool, message us on myCigna.com. You also can call us at the toll-free number on your ID Card. A Customer Service Associate is available to help you 24/7/365. For definitions of common medical and insurance terms, see the glossary on Cigna.com.

Surprise Billing

If you have coverage under an Arizona sitused plan and you receive a bill for out-of-network services rendered during an emergency or from an out-of-network provider at an in-network setting, state consumer protections may apply. Please contact Cigna Healthcare or AZ DOI for more information or if you believe you are being balanced billed.

Arkansas Quarterly Prior Authorization Statistics: Q3 2025 [PDF]
Arkansas Quarterly Prior Authorization Statistics: Q2 2025 [PDF]
Arkansas Quarterly Prior Authorization Statistics: Q1 2025 [PDF]
Arkansas Quarterly Prior Authorization Statistics: Q4 2024 [PDF]
Arkansas Quarterly Prior Authorization Statistics: Q3 2024 [PDF]
Arkansas Quarterly Prior Authorization Statistics: Q2 2024 [PDF]
Arkansas Quarterly Prior Authorization Statistics: Q1 2024 [PDF]
Arkansas Quarterly Prior Authorization Statistics: Q4 2023 [PDF]
Arkansas Quarterly Prior Authorization Statistics: Q3 2023 [PDF]
Arkansas Quarterly Prior Authorization Statistics: Q2 2023 [PDF]
Arkansas Quarterly Prior Authorization Statistics: Q1 2023 [PDF]
Arkansas Quarterly Prior Authorization Statistics: Q4 2022 [PDF]
Arkansas Quarterly Prior Authorization Statistics: Q3 2022 [PDF]
Arkansas Quarterly Prior Authorization Statistics: Q2 2022 [PDF]
Arkansas Quarterly Prior Authorization Statistics: Q1 2022 [PDF]
Arkansas Quarterly Prior Authorization Statistics: Q4 2021 [PDF]
Arkansas Quarterly Prior Authorization Statistics: Q3 2021 [PDF]
Arkansas Quarterly Prior Authorization Statistics: Q2 2021 [PDF]
Arkansas Quarterly Prior Authorization Statistics: Q1 2021 [PDF]
Arkansas Quarterly Prior Authorization Statistics: Q4 2020 [PDF]
Arkansas Quarterly Prior Authorization Statistics: Q3 2020 [PDF]
Arkansas Quarterly Prior Authorization Statistics: Q2 2020 [PDF]
Arkansas Quarterly Prior Authorization Statistics: Q1 2020 [PDF]

Surprise Billing

If you have coverage under an Arkansas sitused plan and you receive a bill from an out-of-network provider at an in-network setting, state consumer protections may apply. Please contact Cigna Healthcare or AR DOI for more information or if you believe you are being balanced billed.

California Health Plan Information
For information about Cigna Healthcare Individual and Family Health plans and services in your area, go to https://www.cigna.com/individuals-families/shop-plans/health-insurance-plans. For group/employer health plan information, including Cigna Healthcare companies, accessing group plan services and information about COBRA/conversion privileges, utilization review and grievances/appeals, visit https://www.cigna.com/individuals-families/member-guide/customer-forms/cigna-in-california.html.

Disclosure Required of Retail Sellers Under California Civil Code Sec. 1714.43
Cigna Healthcare Home Delivery Pharmacy does not make efforts to identify or eradicate human trafficking from its direct supply chains for tangible goods that it offers for sale.

Surprise Billing

If you have coverage under a California sitused plan and you receive a bill for out-of-network services rendered during an emergency or from an out-of-network provider at an in-network setting, state consumer protections may apply. Please contact Cigna Healthcare or CA DOI for more information or if you believe you are being balanced billed.

State of Colorado Notice – ACCESS PLAN
Our Access Plans provide information on: (1) who participates in our provider network; (2) how we ensure that the network meets the health care needs of our members; (3) how our provider referral process works; (4) how care is continued if providers leave our network; (5) what steps we take to ensure medical quality and customer satisfaction; (6) where you can go for information on other policy services and features. The Access Plan is designed to disclose all the policy information required under Colorado law, and is available for your review.

Colorado Surprise Billing Disclosure [PDF]

Colorado Exposure Notification Application [PDF]

Colorado Annual Prior Authorization statistics: 2024 [PDF]

Colorado Annual Prior Authorization statistics: 2023 [PDF]

Colorado Annual Prior Authorization statistics: 2022 [PDF]

Colorado Annual Prior Authorization statistics: 2021 [PDF]

Colorado Annual Prior Authorization statistics: 2020 [PDF]

Colorado Annual Prior Authorization statistics: 2019 [PDF]

Surprise Billing

If you have coverage under a Colorado sitused plan and you receive a bill for out-of-network services rendered during an emergency or from an out-of-network provider at an in-network setting or from an out -of-network Air Ambulance provider, state consumer protections may apply. Please contact Cigna Healthcare or CO DOI for more information or if you believe you are being balanced billed.

Surprise Bills

If you have coverage under a Connecticut sitused plan and you receive a bill for out-of-network services rendered during an emergency or from an out-of-network provider at an in-network setting, state consumer protections may apply. Please contact Cigna Healthcare or CT DOI for more information or if you believe you are being balanced billed.

Connecticut (CT) law protects health insurance and HMO customers from “surprise bills” by health care providers that do not participate in the customer’s health plan network.

A “surprise bill” is a bill that the customer receives for an out-of-network service, when he or she did not knowingly choose an out-of-network health care provider to perform the service. Surprise bills do not include charges for planned services that the customer knows in advance will be performed by an out-network provider.

Surprise bills occur when, without the customer’s knowledge or choice, the out-of-network provider performs a service:

In an in-network facility, or
During a procedure that also involves an in-network provider, or
During a procedure that was authorized beforehand by the insurance carrier, but then referred or transferred to an out-of-network provider.

When a customer receives a surprise bill for a service that is covered under his or her CT health insurance or HMO plan, the insurance carrier will provide coverage as if the service was performed by an in-network health care provider. In other words, the customer will pay no more than the cost share amount he or she would pay for in-network services under the plan. The out-of-network health care provider is barred from requesting any payment from the customer, other than the cost-sharing amount the customer pays for in-network services under the plan.

Surprise Billing

If you have coverage under a Delaware sitused plan and you receive a bill for out-of-network services rendered during an emergency or from an out-of-network provider at an in-network setting or from an out -of-network Air Ambulance provider, state consumer protections may apply. Please contact Cigna Healthcare or DE DOI for more information or if you believe you are being balanced billed.

Mental Health and Substance Use Disorder Benefits

Insurance coverage and benefits for mental health and substance use disorder services can vary depending on the type of health insurance policy or contract a person is covered under, including if it is an individual, small group or large group health plan and when the policy was originally issued. Coverage requirements are dictated by state and/or federal law based on these and other factors.

State Law:

Florida law requires insurers of group health plans to make available to the policyholder (i.e. employer) coverage for mental health and substance use disorder services. If the policyholder elects to have mental health and substance use disorder coverage it must comply with the federal Mental Health Parity and Addiction Equity Act (MHPAEA) unless the policyholder is exempt. Coverage under Florida law cannot apply any financial requirement or quantitative treatment limitation on mental health or substance use disorder benefits that is more restrictive than the predominant financial requirement or quantitative treatment limitation that is applied to substantially all medical/surgical benefits.

Federal Law:

The federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) aims to eliminate coverage discrimination between policyholders or members who are seeking mental health or substance use disorder (MH/SUD) benefits and those seeking medical and surgical care. A lack of parity can prevent a person from pursuing needed care due to cost or limited access, or otherwise make it more expensive or more time intensive than medical visits.

The MHPAEA was passed by Congress in 2008 with the purpose of providing added protections to the Mental Health Parity Act (MHPA) that was passed in 1996. Combined, these federal laws require parity with medical and surgical benefits for annual and aggregate lifetime limits, financial requirements, treatment limitations, and in- and out-of-network coverage, if a plan provides coverage for mental health and substance use disorder services. Quantitative treatment limitations (QTL) refer to the financial limitations such as coverage limits or out-of-pocket expenses (copayment, deductible, or coinsurance, and out of pocket maximums). Example: If most copayments under a plan for medical or surgical office visits are not usually more than $30, the copayments for office visits to mental health and substance use disorder professionals should be around the same amount.

Non-quantitative treatment limitations (NQTL) refer to non-numerical standards, such as medical-management standards, pre-authorization, formularies for prescriptions, and fail-first policies or step-therapy protocols. Standards for medical necessity determinations and reasons for any denial of benefits relating to MH/SUD must be disclosed by the insurer upon request.

The requirements of the MHPA and MHPAEA applied primarily to large group health plans until the passage and implementation of the Affordable Care Act (ACA). Small group and individual qualified health plans effective on or after January 1, 2014, are required to provide ten essential health benefits, with one of the benefits being coverage for mental health and substance use disorders. Federal guidelines require individual and small group plans subject to the ACA to meet the requirements of the MHPAEA to satisfy the essential health benefit mandate. Grandfathered and transitional individual and small group health plans are not required to include mental health and substance use disorder benefits and are not subject to requirements of the ACA as it relates to mental health and substance use disorder benefits. However, if a grandfathered or transitional individual health plan includes mental health and substance use disorder benefits, it must comply with the requirements of the MHPAEA.

Individuals needing assistance with mental health or substance use disorder benefits can call the Cigna Healthcare number on their ID card or they can contact the Florida Consumer helpline by:

Florida Insurance Consumer Helpline
Statewide/Toll-free: 1 (877) 693-5236 Out of State: 1 (850) 413-3089
Fax: 1 (850) 413-1550
Email: Consumer.Services@myfloridacfo.com
Online: Online Insurance Assistance

Provider Performance Outcome and Financial Data Disclosures
Customers are encouraged to view Florida provider performance outcome and financial data that will be posted on the Agency for Health Care Administration’s Health Information website: http://www.floridahealthfinder.gov/index.html.

For more information, please call or write us at:

Cigna Healthcare, 3111 W. Dr. Martin Luther King Jr. Blvd
Tampa, FL 33607

Office hours: 8 am to 5 pm (EST) Monday through Friday
Telephone: 1 (813) 637-1200 Fax: 1 (813) 637-1264
For Customer inquiries, call our Nationwide Customer Services Telephone Number: 1 (800) 244-6224 (Please note: If you are enrolled in an employer-sponsored plan, this number may be different for your employer group. Please check your ID card for the correct Customer Services telephone number.)

If you’re a current Cigna Healthcare customer, you can also login to myCigna.com or use the myCigna^® app to request ID cards, check claim status, verify coverage and change your Primary Care Provider (PCP).

Employer, Broker and Provider Inquiries – please telephone 1 (813) 637-1200 and follow the phone prompts.

Surprise Billing

If you have coverage under a Florida sitused plan and you receive a bill for out-of-network services rendered during an emergency or from an out-of-network provider at an in-network setting or from an out -of-network Air Ambulance provider, state consumer protections may apply. Please contact Cigna Healthcare or FL DOI for more information or if you believe you are being balanced billed.

Surprise Billing

If you have coverage under a Georgia sitused plan and you receive a bill for out-of-network services rendered during an emergency or from an out-of-network provider at an in-network setting or from an out -of-network Air Ambulance provider, state consumer protections may apply. Please contact Cigna Healthcare or GA DOI for more information or if you believe you are being balanced billed.

Georgia Annual Prior Authorization statistics: 2024 [PDF]

GA National Average Drug Acquisition Cost (NADAC) Report

2022-Period 1 [PDF]

2022-Period 2 [PDF]

The following disclosure information is available to Hawaii customers:

A list of participating providers which must be updated on a regular basis indicating at least their specialty and whether the provider is accepting new patients;

Our provider directory can be located at https://hcpdirectory.cigna.com/web/public/consumer/directory

A complete description of benefits, services, and copayments;

For existing customers, this description is available by registering with myCigna.com. For prospective customers, please contact Cigna Healthcare at 1 (800) 244-6224

A statement on enrollee's rights, responsibilities, and obligations;

Please see the "General Disclaimer" and "Exclusions and Limitations" sections on the top of this page.

An explanation of the referral process, if one exists;

Referral procedures, which include the procedures to be followed for consulting a provider other than the primary care provider, utilization review procedures for obtaining precertification, information on our formulary and other policies can be located at http://www.cigna.com/legal/members/member-rights-and-responsibilities/cigna-health-care-policies

Where services or benefits may be obtained;

Our provider directory can be located at https://hcpdirectory.cigna.com/web/public/consumer/directory

Information on complaints and appeals procedures; and
A copy of the grievance process for claim or service denial and for dissatisfaction with care can be located at https://www.cigna.com/individuals-families/member-guide/appeals-grievances
The telephone number of the insurance division;

Department of Commerce and Consumer Affairs:
1 (808) 586-2790 or 1 (808) 586-2799

The following disclosure information is available to Hawaii customers:

A list of participating providers which must be updated on a regular basis indicating at least their specialty and whether the provider is accepting new patients;

Our provider directory can be located at https://hcpdirectory.cigna.com/web/public/consumer/directory

A complete description of benefits, services, and copayments;

For existing customers, this description is available by registering with myCigna.com. For prospective customers, please contact Cigna Healthcare at 1 (800) 244-6224

A statement on enrollee's rights, responsibilities, and obligations;

Please see the "General Disclaimer" and "Exclusions and Limitations" sections on the top of this page.

An explanation of the referral process, if one exists;

Where services or benefits may be obtained;

Our provider directory can be located at https://hcpdirectory.cigna.com/web/public/consumer/directory

Information on complaints and appeals procedures; and
A copy of the grievance process for claim or service denial and for dissatisfaction with care can be located at https://www.cigna.com/individuals-families/member-guide/appeals-grievances
The telephone number of the insurance division;

Department of Commerce and Consumer Affairs:
1 (808) 586-2790 or 1 (808) 586-2799

Cigna Dental Care (DHMO) Plans
In Illinois, the Cigna Dental Care plan is considered a prepaid dental plan.

Surprise Billing

If you have coverage under an Illinois sitused plan and you receive a bill for out-of-network services rendered during an emergency or from an out-of-network provider at an in-network setting or from an out -of-network Air Ambulance provider, state consumer protections may apply. Please contact Cigna Healthcare or IL DOI for more information or if you believe you are being balanced billed.

Illinois Annual Prior Authorization statistics: 2024 [PDF]

Illinois Annual Prior Authorization statistics: 2023 [PDF]

Illinois Annual Prior Authorization statistics: 2022 [PDF]

Illinois Annual Prior Authorization statistics: 2021 [PDF]

Surprise Billing

If you have coverage under a Indiana sitused plan and you receive a bill for out-of-network services rendered during an emergency or from an out-of-network provider at an in-network setting or from an out -of-network Air Ambulance provider, state consumer protections may apply. Please contact Cigna Healthcare or IN DOI for more information or if you believe you are being balanced billed.

Indiana Annual Prior Authorization statistics: 2024 [PDF]

Indiana Annual Prior Authorization statistics: 2023 [PDF]

Special information for policies in Maine
Your health plan may include prescription drug benefits. The following lists (also known as formularies) show which drugs Cigna Healthcare may cover with your plan. Some of these drugs may need special approval to get them. Cigna Healthcare calls this special approval utilization review, prior authorization or step therapy. It’s important that you know how your prescription drug benefits work. How much you pay, and what drugs are available, all depend on the health plan you have. For example:

The cost of your medicine depends on the plan you have. Your plan also directs how we apply that cost to any deductible or out of pocket maximum.
Whether or not there are any drugs not covered depends on your plan.
Any limits or rules about the use of or how much drug you can get depends on your plan and/or drug safety considerations.
The amount of coverage Cigna Healthcare allows when you use an out-of-network doctor depends on your plan.
The amount of coverage Cigna Healthcare allows for drugs not covered also depends on your plan.
Finally, if it’s medically necessary that you see an out-of-network doctor or use a non-covered drug, you may have the right to appeal. This too depends on your plan.

Surprise Billing

If you have coverage under a Maine sitused plan and you receive a bill for out-of-network services rendered during an emergency or from an out-of-network provider at an in-network setting or from an out -of-network Air Ambulance provider, state consumer protections may apply. Please contact Cigna Healthcare or ME DOI for more information or if you believe you are being balanced billed.

Advanced Directives

Electronic Advance Directives (maryland.gov) [PDF]

CRISP Webpage and Advance Directives Information

Maryland Mental Health Parity Reports 2022

EPO-MHDP0100 HDHP Open Access Plus Network Only [PDF]

EPO-MOAP0100 Open Access Plus Network Only [PDF]

EPO-OAI Essential Open Access In-Network [PDF]

EPO-OAPIN Open Access Plus In-Network (Excluding CA) [PDF]

EPO-OAPN1 Open Acess Plus In-Network [PDF]

PPO-HSAF Health Savings Account - Family [PDF]

PPO-MOAP0001 Open Access Plus [PDF]

PPO-NTPOS Network Point of Service [PDF]

PPO-OAP Traditional Open Access Plan [PDF]

PPO-OAP1 Open Access Plus - Non CA [PDF]

Maryland Mental Health Parity Reports 2021

Indemnity-PRIND Puerto Rico Indemnity Plan [PDF]

PPO-MOAP0001 Open Access Plus Plan [PDF]

PPO-HSAF Health Savings Account - Family Plan [PDF]

PPO-OAP Traditional Open Access Plan [PDF]

PPO-OAP1 Open Access Plus Plan- Non CA [PDF]

PPO-NTPOS Network Point of Service [PDF]

EPO-MOAP0100 Open Access Plus Network Only Plan [PDF]

EPO-MHDP0100 HDHP Open Access Plus Network Only Plan [PDF]

EPO-OAPIN Open Access Plus In-Network Plan (Excluding CA) [PDF]

EPO-OAPN1 Open Access Plus In-Network Plan [PDF]

EPO-OAI Essential Open Access In- Network Plan [PDF]

Median Appointment Wait Times for All Networks

Fourth Quarter 2025 Median Appointment Waiting Times [PDF]

Second Quarter 2025 Median Appointment Waiting Times [PDF]

Fourth Quarter 2024 Median Appointment Waiting Times [PDF]

April 2024 Median Appointment Waiting Times [PDF]

October 2023 Median Appointment Waiting Times [PDF]

Surprise Billing

If you have coverage under a Maryland sitused plan and you receive a bill for out-of-network services rendered during an emergency or from an out-of-network provider at an in-network setting, state consumer protections may apply. Please contact Cigna Healthcare or MD DOI for more information or if you believe you are being balanced billed.

Annual Behavioral Health Wellness Exam

Fully insured health plans issued in Massachusetts are required to cover an annual behavioral wellness exam performed by a licensed mental health professional or your primary care provider. This exam will be covered at no cost share unless you are enrolled in a High-Deductible Health Plan (HDHP) with a Health Savings Account (HSA). Please refer to your benefits booklet for specific details about your coverage.

LocalPlus^® Plans

This plan provides access to a network that is smaller than our national Open Access Plus (OAP) and Preferred Provider Organization (PPO) Networks. In this plan customers have access to in-network benefits only from the health care providers in the LocalPlus Network when in a LocalPlus Network service area. Please consult the limited network directory or visit our online directory to determine which providers are included in the LocalPlus Network. For a paper copy, ask your employer or contact Cigna Healthcare.

Surprise Billing

If you have coverage under a Massachusetts sitused plan and you receive a bill from an out-of-network provider at an in-network setting, state consumer protections may apply. Please contact Cigna Healthcare or MA DOI for more information or if you believe you are being balanced billed.

Surprise Billing

If you have coverage under a Michigan sitused plan and you receive a bill for out-of-network services rendered during an emergency or from an out-of-network provider at an in-network setting or from an out -of-network Air Ambulance provider, state consumer protections may apply. Please contact Cigna Healthcare or MI DOI for more information or if you believe you are being balanced billed.

Cigna Dental Care (DHMO) Plans – Out-of-Network Services
If you are considering enrollment or are enrolled in a Cigna Dental Care (DHMO) plan through your employer, you must visit your selected network dentist in order for the charges on the Patient Charge Schedule to apply. You may also visit other dentists that participate in our network or you may visit dentists outside the Cigna Dental Care network. If you do, the fees listed on the Patient Charge Schedule will not apply. You will be responsible for the dentist’s usual fee. We will pay 50% of the value of your network benefit for those services. Of course, you’ll pay less if you visit your selected Cigna Dental Care network dentist. Call Customer Service for more information.

Surprise Billing

If you have coverage under a Minnesota sitused plan and you receive a bill from an out-of-network provider at an in-network setting, state consumer protections may apply. Please contact Cigna Healthcare or MN DOI for more information or if you believe you are being balanced billed.

Minnesota Annual Prior Authorization statistics: 2024 [PDF]

Minnesota Annual Prior Authorization statistics: 2023 [PDF]

Minnesota Annual Prior Authorization statistics: 2022 [PDF]

Minnesota Annual Prior Authorization statistics: 2021 [PDF]

Surprise Billing

If you have coverage under a Missouri sitused plan and you receive a bill for out-of-network services rendered during an emergency or from an out-of-network provider at an in-network setting, state consumer protections may apply. Please contact Cigna Healthcare or MO DOI for more information or if you believe you are being balanced billed.

Surprise Billing

If you have coverage under a Nebraska sitused plan and you receive a bill for out-of-network services rendered during an emergency or from an out-of-network provider at an in-network setting or from an out -of-network Air Ambulance provider, state consumer protections may apply. Please contact Cigna Healthcare or NE DOI for more information or if you believe you are being balanced billed.

Surprise Billing

If you have coverage under a New Hampshire sitused plan and you receive a bill for out-of-network services rendered during an emergency or from an out-of-network provider at an in-network setting, state consumer protections may apply. Please contact Cigna Healthcare or NH DOI [PDF] for more information or if you believe you are being balanced billed.

New Jersey State Department of Banking and Insurance Notice for Extensions to Grace Periods

The New Jersey State Department of Banking and Insurance requires us to share information about extensions to grace periods and other rights under your life insurance policy if you can demonstrate financial hardship as a result of the COVID-19 pandemic. This notice only applies to New Jersey policy/certificate holders with the following insurance policy/plan type with Cigna Healthcare:

Group Term Life Insurance underwritten by Life Insurance Company of North America (LINA)
Group Universal Life Insurance underwritten by Connecticut General Life Insurance Company (CGLIC)
Individual Whole Life policies underwritten by LINA and CGLIC

Please click here [PDF] to access the notice.

NEW JERSEY OUT-OF NETWORK CONSUMER PROTECTION, TRANSPARENCY, COST CONTAINMENT AND ACCOUNTABILITY ACT [PDF]

NEW JERSEY OUT-OF-NETWORK CONSUMER PROTECTION, TRANSPARENCY, COST CONTAINMENT AND ACCOUNTABILITY ACT: ESTIMATED REIMBURSEMENT FOR FREQUENTLY BILLED OUT-OF-NETWORK SERVICES [PDF]

National Drug Pricing Source

Cigna Healthcare uses data from Medi-Span to determine the average wholesale price of prescription drugs not included on the maximum allowable cost list.

Surprise Billing

If you have coverage under a New Jersey sitused plan and you receive a bill for out-of-network services rendered during an emergency or from an out-of-network provider at an in-network setting, state consumer protections may apply. Please contact Cigna Healthcare or NJ DOI for more information or if you believe you are being balanced billed.

New Jersey Annual Prior Authorization statistics: 2024 [PDF]

The advertising, sales and other marketing information on this site is not intended for residents of New Mexico. If you would like more information about Cigna Healthcare plans and services in your state, please contact your licensed agent or Cigna Healthcare sales representative.

Surprise Billing

If you have coverage under a New Mexico sitused plan and you receive a bill for out-of-network services rendered during an emergency or from an out-of-network provider at an in-network setting or from an out -of-network Air Ambulance provider, state consumer protections may apply. Please contact Cigna Healthcare or NM DOI for more information or if you believe you are being balanced billed.

NM Substance Use Disorder (SUD)

Starting on November 8, 2023, Cigna Healthcare has expanded out-of-network treatment benefits for substance use disorders for the state of New Mexico. Coverage details are in the below documents.

Expansion of Substance Use Disorder Benefits [PDF]

Amended Emergency Order [PDF]

COVID-19 specific PPE disclosures

NOTICE REGARDING CHARGES FOR PERSONAL PROTECTIVE EQUIPMENT ("PPE"). Please be advised that you are not responsible for any charges received from a participating provider beyond your applicable deductible, copayment, or coinsurance, include any fees charged for PPE. If you have paid PPE charges to a participating provider, you should contact the provider and obtain a refund. If you would like to submit a complaint to us about charges for PPE from a participating provider, please contact us at 1 (800) 244-6224.

New York State Department of Financial Services Notice for Extensions to Grace Periods

The New York State Department of Financial Services requires us to share information about extensions to grace periods and other rights under your life insurance policy if you can demonstrate financial hardship as a result of the COVID-19 pandemic. This information pertains only to certain Cigna Healthcare insurance policies they may have, that are known as:

Group Term Life Insurance underwritten by Cigna Life Insurance Company of New York (CLICNY) issued to New York employers.
Life Insurance Port and Conversions (individual policies) underwritten by Connecticut General Life Insurance Company (CGLIC) issued to insureds residing in New York.

Please click here [PDF] to access the notice.

OUT-OF-NETWORK COVERAGE

NEW YORK INSURANCE POLICIES

Out-of-network Benefits - What's my Cost?
If your plan provides out-of-network benefits, your cost for a covered health service depends on an estimated total payment for the service in your area. The share that you pay for the out-of-network service is a share of that estimated total payment.

How We Estimate Total Payments

Each employer or plan sponsor chooses the estimated total payment for out-of-network services. Depending on the plan options chosen by the employer or group plan sponsor, the total payment for out-of-network services is estimated based on either:

(1) a fixed percentile of the charges by similar providers in the same geographic area, for the same service;

(2) a fixed percentage of a fee schedule similar to Medicare, for the same service in the same geographic area.

For example, the plan may estimate the total payment as 80% of the charges by similar providers in the area for the services.

The Provider’s Billed Charge

Out-of-network providers may bill a carrier any amount for a covered health service. For example, a specialist can often bill higher amounts than what other specialists in the area normally charge for the same service, and will often bill higher amounts than what Medicare pays. Out-of-network provider bills are also usually higher than the rates that in-network providers agree to receive for the same health service.

Get information from your provider:

If your provider does not participate in your health plan’s provider network, your provider must tell you the estimated amount the practice will bill you for services, if you ask. Your provider must also give you the name and practice name, address and phone number of any anesthesiology, laboratory, pathology, radiology or assistant surgeon specialists that he or she schedules for you or refers you to for services.
All hospitals are required to post a list of their charges on their websites, or show on their websites how to obtain this information. Hospitals are also required to tell you about charges by doctors whose services at the hospital are not included in the hospital's charges; these doctors may or may not participate in your health plan network and you should ask your arranging provider if any doctor scheduled to perform services is in your network.

New York State, and Benchmark Amounts

The State of New York requires a specific “usual and customary” definition, to create a benchmark cost amount for out-of-network health services. The benchmark amount is available for insurance customers to compare provider bills and plan payments. The State’s “usual and customary” benchmark cost amount is defined this way:

“the 80^th percentile of all charges for the particular health care service performed by a provider in the same or similar specialty and provided in the same geographical area, as reported in a benchmarking database maintained by a nonprofit organization”.

The organization that provides the benchmark database for this purpose is Fair Health, Inc., as required by the New York State Department of Financial Services. The organization also provides an online benchmark cost calculator, for a fee paid by carriers. You can use their Consumer Cost Lookup page, free of charge, to look up a benchmark cost amount for common health care services in your geographic area. The website to access the Consumer Cost Lookup page is: http://www.fairhealthconsumer.org/

(for questions about navigating this site, a customer can call 1 (855) 566-5871, Mon-Fri 9 am -6 pm EST

Comparing the Cost of Out-of-Network Services

As you can see above, what you pay for covered out-of-network services is based on three things: (1) the provider’s billed charge; (2) the way your plan estimates total charges; and (3) the benefit share your plan pays for out-of-network services. The provider may bill a higher amount than the plan’s estimated charge, but if the provider accepts the plan’s estimated total payment the share you pay will be less.

The New York “usual and customary” benchmark amount may be higher or lower than your plan pays. Plans that estimate the total payments as the 80^th percentile of provider charges in the geographic area pay amounts that are generally alike the New York “usual and customary” benchmark amount. If the plan estimates total payments with a lower percentile of charges in the area, the plan’s estimated total will be lower than “usual and customary” benchmark and the share you pay may be less.

You can refer to your plan documents to see the method and fixed percentile or percentage your plan uses to estimate total payments. Your plan documents also show the benefit share that the plan pays for out-of-network services, and the share that you pay.

If your plan provides both in-network and out-of-network benefits, you will always pay less if you get your health services in-network from one of our credentialed network health professionals.

You can go to this link to look up the approximate dollar amount that your plan will pay for a specific in-network service: http://hcpdirectory.cigna.com/web/public/providers.

You can also call the toll-free help number on your health care plan ID card to help you find an in-network provider or to request the approximate dollar amount that your plan will pay for a specific in-network or out-of-network service, or examples of out-of-network costs for certain common services (colonoscopy, laminotomy, and breast reconstruction).

Filing Out-of-Network Claims

If you assign claim payment for covered services to your out-of-network health care provider, your provider will normally file the claims and will receive the payments directly.

Otherwise, you may file claims on your own behalf. You can go to this link to download the applicable claim forms for covered services: https://my.cigna.com/web/secure/my/forms. Completed claim forms should be mailed to the Cigna Healthcare address listed on your ID card.

If you have additional questions, or would like to fax or email your completed claim forms, please contact Customer Service using the toll-free number on your ID card. Completed claim forms may also be faxed to these numbers:

If the Cigna Healthcare address listed on your ID card is PO Box 182223, you may fax to 1 (859) 410-2422
If the Cigna Healthcare address listed on your ID card is PO Box 188061, you may fax to 1 (859) 410-2440

Out-of-network "Surprise Bill" and Emergency Service Claims

At a Glance

Customers will get in-network benefits for out-of-network ‘surprise bill’ and emergency services. The out-of-network health care provider and carrier are required to protect the customer from any additional ‘balance billing’ by the provider, after the carrier benefits are paid.

Customers will get disclosures from physicians and hospitals, describing the potential costs and benefit reductions for other kinds of services rendered or referred out-of-network. Customers can also request from carriers a benefit estimate for those services.

Health Care Providers that render out-of-network ‘surprise bill’ or emergency services will get the opportunity to negotiate carrier payments, according to usual & customary cost guidelines. In-state providers may request an Independent Dispute Resolution review, when agreement on a payment amount is not reached.

Carriers will pay in-network benefits for out-of-network ‘surprise bill’ and emergency services. Carriers that are billed for out-of-network ‘surprise bill’ or emergency services will get the opportunity to negotiate payments, according to usual & customary cost guidelines. When billed by an in-state provider, the carrier may request an Independent Dispute Resolution review if agreement is not reached on a payment amount.

Carriers will pay customer benefit amounts directly to the provider if the customer assigns payment. Carriers will also furnish disclosures to customers regarding benefit payment and balance billing protection for these services.

Affected Claims

‘Surprise Bills’

An out-of-network ‘surprise bill’ is any one of the following:

(1) A bill from an out-of-network physician at a network hospital/ambulatory surgical center, in instances where:

a participating provider was not available; or
the non-participating physician rendered services without the member's knowledge; or
unforeseen medical services arose at the time the health care services were rendered.

(2) A bill from an out-of-network provider whose services were referred by a network physician, without explicit written consent from the customer acknowledging that he or she was aware the network physician was referring to an out-of-network provider.

This includes common surprise bill instances, such as out-of-network anesthesiologists or assistant surgeons in a network hospital/surgical center, and network PCP referrals to out-of-network specialty services in or outside the PCP’s office. A bill from an out-of-network provider that the customer chose to go to, when a network provider was available, is not a surprise bill.

Emergency Claims

The out-of-network emergency claims covered as in-network benefits, and negotiated/paid without additional balance billing to the customer, include claims screening, examining and treating to stabilize any emergency condition by the hospital’s emergency department and facility staff.

Emergency conditions include any medical and behavioral condition that a layperson with average knowledge could reasonably expect to:

place the patient in serious jeopardy (or others, in the case of behavioral conditions);
seriously impair bodily functions, or make a body part or organ dysfunctional;
seriously disfigure a person; or
pose a threat to the health or safety of a pregnant woman in contraction or her unborn child,

in the absence of immediate medical attention by the out-of-network emergency provider.

Carrier Payments to Out-of-network Providers

Emergency Services

Carrier payment to an out-of-network emergency service may be ‘reasonable amount’ within the usual and customary range, or a negotiated amount or billed charge.

If the carrier pays a ‘reasonable amount’, the amount must be consistent with the carrier’s benefit policy description of payment methods for out-of-network emergency claims. If the policy describes a range of payment methods or amounts, the payment must be the greater of the amounts described. New York regulators now require carriers to use state-modeled language for these policy descriptions, and so the payment method and amounts will fall within consistent ranges.

Like for ‘Surprise Bills’, the provider or carrier may request an Independent Dispute Resolution review of the carrier’s payment or the provider’s billed amount, with the understanding that the arbitrator will require both parties to accept either one or the other of those amounts (no compromises). Carriers that request a review will notify the customer not to pay any balance bill.

For “low cost” emergency services (certain procedures billed for $600 or less, at 120% or less of the usual and customary rate), slightly different rules apply. Here, carriers pay a negotiated amount or billed charge, and no Independent Dispute Resolution is available.

Claim Notices for 'Surprise Bill' and Emergency Claims

Carriers will provide the following information to customers, in a claim notice or in the explanation of benefits (EOB) for the claim:

Explanation that the customer’s out-of-pocket cost will be no greater than the in-network benefit cost share;
Explanation that the customer’s final cost share may increase, if the Independent Dispute Resolution process requires carrier payment of a provider’s higher billed charge ;
Direction to contact the carrier if the provider balance-bills the customer for the out-of-network service; and
Direction to the carrier’s website for additional information about surprise bills (if a surprise bill claim).

Independent Dispute Resolution for Surprise Bills & Emergency Claims

Customers

Customers can request an Independent Dispute Resolution review of a New York out-of-network provider ‘surprise bill’. To request the review, the customer must:

Complete the Application available from the New York Department of Financial Services; and
Send the Form to NYS Department of Financial Services, Consumer Assistance Unit/IDR Process,

One Commerce Plaza, Albany, NY 12257.

Out of Network Health Care Providers

Providers in New York can request an independent arbitration review of carrier payment amounts for a ‘surprise bill’ or emergency service bill. To submit a dispute, health care providers must:

visit the Department of Financial Services (DFS) website to receive a file number;
complete the Application available from the New York Department of Financial Services; and
send the application to the assigned independent dispute resolution entity.

Independent Dispute Resolution Decisions

The Independent Dispute Resolution arbitrator will make a binding decision on all parties to accept either:

(a) the provider’s charge as originally billed; or (b) the carrier’s payment amount as originally determined for the bill (no compromises). In some cases, if settlement looks likely or if the carrier payment and provider fee are unreasonably far apart, the arbitrator may direct the provider and carrier to negotiate a settlement directly.

Independent Dispute Resolution decisions are made within 30 calendar days after the application is received. The decision is based on these factors:

Whether there’s a gross disparity between the provider’s charge and (1) charges paid for the same services to other patients for other carriers out-of-network, and (2) the fees paid by the carrier to similarly qualified out-of-network providers for the same services in the same region;
The provider's training, education, experience, and usual charge for comparable services when the provider does not participate with the patient's health plan;
The circumstances and complexity of the case, and patient characteristics; and
The usual and customary cost of the service.

New York Independent Dispute Resolution Application Form: https://www.dfs.ny.gov/consumers/health_insurance/surprise_medical_bills

Customers or providers with questions on the Independent Dispute Resolution process may call 1 (800) 342-3736,

or email IDRquestions@dfs.ny.gov.

Surprise Billing

If you have coverage under a North Carolina sitused plan and you receive a bill for out-of-network services rendered during an emergency or from an out-of-network provider at an in-network setting or from an out -of-network Air Ambulance provider, state consumer protections may apply. Please contact Cigna Healthcare or NC DOI for more information or if you believe you are being balanced billed.

Surprise Billing

If you have coverage under a North Dakota sitused plan and you receive a bill for out-of-network services rendered during an emergency or from an out-of-network provider at an in-network setting or from an out -of-network Air Ambulance provider, state consumer protections may apply. Please contact Cigna Healthcare or ND DOI for more information or if you believe you are being balanced billed.

Surprise Billing

If you have coverage under an Ohio sitused plan and you receive a bill for out-of-network services rendered during an emergency or from an out-of-network provider at an in-network setting, state consumer protections may apply. Please contact Cigna Healthcare or OH DOI for more information or if you believe you are being balanced billed.

Cigna Dental Care (DHMO) Plans – Out-of-Network Services

In Oklahoma, Cigna Dental Care (DHMO) is an Employer Group Pre-Paid Dental Plan. You may also visit dentists outside the Cigna Dental Care network. If you do, the fees listed on the Patient Charge Schedule will not apply. You will be responsible for the dentist’s usual fee. We pay non-network dentists the same amount we’d pay network dentists for covered services. You’ll pay less if you visit a network dentist in the Cigna Dental Care network. Call Customer Service for more information.

Oklahoma Group Policy Form Numbers

Medical: HP-APP-1 et al (Cigna Health and Life Insurance Company, "CHLIC"). Indemnity/Dental PPO: HP-POL99/HP-POL-388 (CHLIC), Cigna Dental Care (DHMO) & Specialty Access: HP-POL115 (CHLIC). Group Universal Life (GUL 2): XX-603404 et al (Connecticut General Life Insurance Company). Disability & Term Life: TL-004700 et al, Disability Reserve Buy Out: TL-008610.37, Blanket Accident: BA-01-1000.00 et al, Group Accident: GA-00-1000.00 et al, Accidental Injury: GAI-00-1000; Critical Illness: GCI-00-1000, GCI-02-1000; Hospital Care (Indemnity): GHIP-00-1000 (Life Insurance Company of North America).

Family Planning and Birth Control Coverage [PDF]

Oregon Group Policy Form Numbers

Medical: HP-POL38 02-13 et al (Cigna Health and Life Insurance Company, “CHLIC”). Dental: Indemnity/PPO: HP-POL68/HP-POL352, DHMO - HP-POL121 04-10 (CHLIC). Group Universal Life (GUL 2): XX-603404 et al (Connecticut General Life Insurance Company). Disability & Term Life: TL-004700 et al, Blanket Accident: BA-01-1000.00 et al, Group Accident: GA-00-1000.00 et al, Accidental Injury: GAI-00-1000.OR et al, Critical Illness: GCI-00-0000.OR & GCI-02-0000.OR et al, Hospital Care (Indemnity): GHIP-00-1000.ORa et al (Life Insurance Company of North America).

Surprise Billing

If you have coverage under an Oregon sitused plan and you receive a bill for out-of-network services rendered during an emergency or from an out-of-network provider at an in-network setting, state consumer protections may apply. Please contact Cigna Healthcare or OR DOI for more information or if you believe you are being balanced billed.

Surprise Billing

If you have coverage under a Pennsylvania sitused plan and you receive a bill for out-of-network services rendered during an emergency or from an out-of-network provider at an in-network setting or from an out -of-network Air Ambulance provider, state consumer protections may apply. Please contact Cigna Healthcare or PA DOI for more information or if you believe you are being balanced billed.

Tennessee Group Policy Form Numbers

Medical: HP-POL43/HC-CER1V1 et al (Cigna Health and Life Insurance Company, “CHLIC”), GSA-COVER, et al (Cigna HealthCare of Tennessee, Inc.). Dental: Indemnity/PPO: HP-POL69/HC-CER2V1/HP-POL389, et al., DHMO - HP-POL134/HC-CER17V1 et al. (CHLIC). Group Universal Life (GUL 2): XX-603404 et al (Connecticut General Life Insurance Company). Disability & Term Life: TL-004700 et al, Blanket Accident: BA-01-1000.00 et al, Group Accident: GA-00-1000.00 et al, Accidental Injury: GAI-00-1000; Critical Illness: GCI-00-1000, GCI-02-1000; Hospital Care (Indemnity): GHIP-00-1000 (Life Insurance Company of North America).

Tennessee Local Contact Information

General Offices:Cigna Healthcare 1111 Market Street, BR6A Chattanooga, TN 37402

Office hours: 8 am to 5 pm (EST) Monday through Friday

Customer Inquiries:
Nationwide Customer Service Telephone Number: 1 (800) 244-6224 (Please note: this number may be different for your employer group. Please check your ID card for the correct Customer Service telephone number.) Customers can also login to myCigna.com or use the myCigna^® app to order ID cards, check claim status, verify coverage or change your Primary Care Provider (PCP).

Benefits Manager Inquiries:

Telephone: 1 (423) 321-5550

Fax: 1 (423) 321-4861

Employer Inquiries:

Telephone: 1 (423) 321-5550

Fax: 1 (423) 321-4861

Provider Inquiries:

Telephone: 1 (800) 832-3211

Fax: 1 (615) 595-3575

Broker Inquiries:

Telephone: 1 (800) 852-7618 Ext. 65549

Fax: 1 (423) 321-4861

Surprise Billing

If you have coverage under a Tennessee sitused plan and you receive a bill for out-of-network services rendered during an emergency or from an out-of-network provider at an in-network setting, state consumer protections may apply. Please contact Cigna Healthcare or TN DOI for more information or if you believe you are being balanced billed.

Product Information
For a list of group/employer health plan products that may be available in Texas, visit https://www.cigna.com/individuals-families/shop-plans/plans-through-employer.

Health Related and Non-Insured Services
Cigna Healthcare health benefit plans provide access to preventive care, health education and other forms of health related programs. Through our local and national wellness programs, customers can receive information and support that can help them learn how to stay fit and enjoy healthier lives. We encourage our customers to take advantage of these important wellness programs. Current programs may include:

Healthy Rewards^®. This program offers discounts on health and wellness programs and services. There are no added membership fees for the Healthy Rewards discount program. Cigna Healthcare customers and their covered family members are already qualified. Examples of services available through the program include discounts on products and services from health clubs, weight management systems, Lasik vision correction and magazine subscriptions. Please log on to myCigna.com or use the myCigna^® app to learn which Healthy Rewards programs are available to you.
Cigna Healthcare 24-hour Health Information Line^SM. We have a toll-free telephone line staffed with trained nurses who can answer questions, provide information about treatment options, and help customers find an appropriate level of care based on their symptoms and location. Additionally, customers can access a Health Information Library of audio tapes on more than 1,000 health conditions and topics.
Cigna Healthcare Healthy Babies program. This program encourages prenatal care and provides important information and resources for parents-to-be. We supply valuable education materials from the March of Dimes including Mama Magazine and other brochures about pregnancy. Customers can also speak to a maternity coach with nursing experience and for help finding answers to any questions about their pregnancy.
Cigna Healthcare Chronic Condition Management programs offer help for these chronic conditions:
1. Asthma
2. Diabetes
3. Heart disease
4. Low back pain
5. Depression
6. Weight complications
7. Chronic Obstructive Pulmonary Disease
8. Targeted conditions*

Each program allows you to design a personalized action plan under your doctor's guidance. We'll provide your doctor with confidential updates on your progress and challenges, and we'll provide you with:

Access to a personal, experienced registered nurse to call for guidance and support
Educational material about your condition
Self-care information
Reminders of important tests and exams
Informational newsletters

*These conditions include acid-related stomach disorders, atrial fibrillation, decubitus ulcer, fibromyalgia, hepatitis C, inflammatory bowel disease, irritable bowel syndrome, osteoarthritis, osteoporosis and urinary incontinence. Availability of programs may depend on your plan or employee benefit program. Please check your plan documents for details.

Frequently Asked Questions

How can I be sure that health plans in Texas match quality standards to those in other states?

Cigna Healthcare is committed to quality and to making information about health care quality, including our own performance, available to consumers and customers. For more information, contact us.

We are pleased that Cigna HealthCare of Texas, Inc. has ranked among the top 200 of "America's Best Health Plans", in U.S. News and World Report for three consecutive years (2006, 2007 and 2008) demonstrating our commitment to quality care and service is yielding strong results. This ranking recognizes our strong performance on clinical quality measures and NCQA accreditation record.

NCQA Accreditation is viewed in the health care industry as a highly rigorous and regarded health plan accreditation program in the health care industry. For an organization to become accredited by NCQA, it must undergo a detailed survey and meet certain standards designed to evaluate the health plan's clinical and administrative systems. NCQA pays special attention to the areas of patient safety, confidentiality, consumer protection, access, service and continuous improvement.

Cigna HealthCare of Texas, Inc. which is currently accredited by NCQA, holds the highest designation rating offered of "Excellent" for its commercial HMO/POS products through February 2010). Cigna HealthCare of Texas also earned "Distinction" status from NCQA for its consumer decision support tools through its Quality Plus Member Connections Program for that same time period.

Cigna Healthcare has been publicly reporting our HEDIS^®* quality results for more than a decade. We believe consumers should have access to this type of publicly-available information. Cigna HealthCare of Texas Effectiveness of Care results have consistently year over year exceeded the Quality Compass National average and/or demonstrated significant/meaningful improvements in several measures.

The Consumer Assessment of Health Providers and Systems (CAHPS^®*) annually evaluates health plan performance in areas such as customer service, access to care and claims processing. Cigna HealthCare of Texas results also continue to show year over year positive trends in several measures 2005 through 2008.

*Healthcare Effectiveness Data and Information Set (HEDIS^®) is a registered trademark of NCQA. CAHPS^® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

Who is eligible for the Texas Health Insurance Risk Pool? The following is a list of criteria that may deem a terminated member eligible for the Risk Pool:

The member must be a resident of Texas and apply for health coverage.
The member must have a written refusal or rejection, based on health reasons, by a health carrier, for substantially similar individual hospital, medical, or surgical coverage.
The member must have a certification from an agent or salaried representative of a health carrier on the Health Insurance Risk Pool's certification form, stating that the agent or salaried representative is unable to obtain substantially similar individual hospital, medical, or surgical coverage for the member from a health carrier the agent or salaried representative represents because, based on that health carrier's underwriting guidelines, the member will be declined for coverage as a result of a medical condition.
The member must have an offer of substantially similar individual hospital, medical, or surgical coverage with riders excluding certain health conditions the member has (for example, a health carrier will provide coverage to the member with an exclusion of coverage for member's diabetes, heart disease, cancer, etc.).
The member must have a diagnosis of one of the medical conditions specified by the Texas Health Pool Board of Directors.6. The member must have proof that health coverage has been maintained for the previous 18 months with no gap in coverage greater than 63 days, with the most recent coverage with an employer-sponsored plan, government plan or church plan.For additional information concerning eligibility, coverage, cost, limitations, exclusions, and termination provisions call or write:

Texas Health Insurance Risk Pool

P. O. Box 6089

Abilene, TX 79608-6089

1 (888) 398-3927

Visit the Texas Health Insurance Risk Pool web site: www.txhealthpool.com

Are hospital based providers (radiologist; anesthesiologist; pathologist; emergency department physician; or neonatologist) considered to be in-network providers?

Some hospital based providers are contracted with Cigna Healthcare and are considered to be in-network providers. However, not all hospital based providers contract with Cigna Healthcare. Although health care services may be or have been provided to you at a health care facility that is a member of the provider network used by your health benefit plan, other professional services may be or have been provided at or through the facility by physicians and other health care practitioners who are not members of that network. You may be responsible for payment of all or part of the fees for those professional services that are not paid or covered by your health benefit plan.

Does Cigna Healthcare provide coverage for acquired brain injuries?

Most Cigna Healthcare insured health benefit plans include coverage for an acquired brain injury, including the following services:

Cognitive rehabilitation therapy;
Cognitive communication therapy;
Neurocognitive therapy and rehabilitation;
Neurobehavioral, neurophysiological, neuropsychological and psychophysiological testing and treatment;
Neurofeedback therapy and remediation;
Post acute transition services and community reintegration services, including outpatient day treatment services or other post acute care treatment services; and
Reasonable expenses related to periodic reevaluation of the care of an individual covered under the plan who has incurred an acquired brain injury, has been unresponsive to treatment, and becomes responsive to treatment at a later date, at which time the cognitive rehabilitation services would be a covered benefit.

The fact that acquired brain injury does not result in hospitalization or acute care treatment does not affect the right of the insured or the enrollee to receive the preceding treatments or services commensurate with their condition. Post acute care treatment or services may be obtained in any facility where such services may be legally provided, including acute or post acute rehabilitation hospitals and assisted living facilities regulated under the Texas Health and Safety code.
You should refer to your insurance certificate or Group Service Agreement for detailed coverage information.

Does Cigna Healthcare provide coverage for prostate cancer screening?

Most Cigna Healthcare insured health benefit plans include coverage for each covered male for an annual medically recognized diagnostic examination for the detection of prostate cancer. Benefits include:

A physical examination for the detection of prostate cancer; and
A prostate-specific antigen test for each covered male who is 1. at least 50 years of age; or 2. at least 40 years of age with a family history of prostate cancer or other prostate cancer risk factor. You should refer to your insurance certificate or Group Service Agreement for detailed coverage information.

Does Cigna Healthcare provide coverage for tests for detection of colorectal cancer?

Most Cigna Healthcare insured health benefit plans include coverage for each person enrolled in the plan who is 50 years of age or older and at normal risk for developing colon cancer. Covered expenses incurred in conducting a medically recognized screening examination for the detection of colorectal cancer include the covered person's choice of:

A fecal occult blood test performed annually and a flexible sigmoidoscopy performed every five years, or
A colonoscopy performed every 10 years. You should refer to your insurance certificate or Group Service Agreement for detailed coverage information.

Does Cigna Healthcare provide coverage for tests for detection of human papillomavirus and cervical cancer?

Most Cigna Healthcare insured health benefit plans include coverage for each woman enrolled in the plan who is 18 years of age or older, for expenses incurred for an annual medically recognized diagnostic examination for the early detection of cervical cancer. Coverage includes, at a minimum, a conventional Pap smear screening or a screening using liquid-based cytology methods, as approved by the United States Food and Drug Administration, alone or in combination with a test approved by the United States Food and Drug Administration for the detection of the human papillomavirus. You should refer to your insurance certificate or GSA for detailed coverage information

Isn't Cigna Healthcare a March of Dimes Sponsor?

Yes. We proudly support the nationwide affiliation and long-time involvement Cigna Healthcare has with the March of Dimes^®. Since 1995, Cigna Healthcare has been the exclusive National Health Care Sponsor of the March of Dimes March for Babies. www.marchofdimes.com

Surprise Billing

If you have coverage under a Texas sitused plan and you receive a bill for out-of-network services rendered during an emergency or from an out-of-network provider at an in-network setting or from an out -of-network Air Ambulance provider, state consumer protections may apply. Please contact Cigna Healthcare or TX DOI for more information or if you believe you are being balanced billed.

Texas Annual Prior Authorization statistics: 2024 [PDF]

Texas Annual Prior Authorization statistics: 2023 [PDF]

Texas Annual Prior Authorization statistics: 2022 [PDF]

Texas Annual Prior Authorization statistics: 2021 [PDF]

Texas Annual Prior Authorization statistics: 2020 [PDF]

Texas Annual Prior Authorization statistics: 2019 [PDF]

Surprise Billing

If you have coverage under a Vermont sitused plan and you receive a bill for out-of-network services rendered during an emergency or from an out-of-network provider at an in-network setting or from an out -of-network Air Ambulance provider, state consumer protections may apply. Please contact Cigna Healthcare or VT DOI for more information or if you believe you are being balanced billed.

If you have coverage under a Virginia sitused plan and you receive a bill for out-of-network services rendered during an emergency or from an out-of-network provider at an in-network setting, state consumer protections may apply. Please contact Cigna Healthcare or VA DOI for more information or if you believe you are being balanced billed.

Virginia Guaranty Association Notice [PDF]

Provider Network Exception

If you cannot locate an in-network provider for a specific service within a reasonable distance and timeframe, you can contact our customer service at the phone number on your ID card or call 1 (800) 244-6224, and Cigna Healthcare will help you locate an appropriate provider for these services. In this situation, where medically necessary covered services are provided out of network because there was no in-network provider within a reasonable distance and timeframe, the out of network services will generally be subject to an in-network level of cost-sharing.

The following disclosure information is available to Washington customers:

A listing of covered benefits, including prescription drug benefits if any, and how consumers may be involved in decisions about benefits, can be found in the Benefit Summary [PDF]

You can also view additional information about how consumers may be involved in decisions about benefits in the grievance processes outlined below.

A listing of exclusions, reductions, and limitations to covered benefits, definitions of terms such as formulary, generic versus brand name, medical necessity or other coverage criteria and policies regarding coverage of drugs, including how drugs are added or removed from the formulary and how consumers may be involved in decisions about benefits can be found in the Benefit Summary listed above. You can also view additional information about how consumers may be involved in decisions about benefits in the grievance processes outlined below and formulary information in the drug formulary listed below.
A statement of the policies for protecting the confidentiality of health information can be located at https://www.cigna.com/legal/compliance/privacy-notices
For information on the cost of premiums and any cost-sharing requirements, please contact your employer. Cost-sharing requirements for current customers can also be located by registering on myCigna.com or contacting Customer Service on the number on the back of your identification card or 1 (800) 244-6224.
View a summary explanation of the grievance process [PDF].
A copy of the grievance process for claim or service denial and for dissatisfaction with care can be located at https://www.cigna.com/individuals-families/member-guide/appeals-grievances
Cigna Healthcare does not operate a point-of-service option in Washington.
To obtain a complete and detailed list of covered benefits including a copy of the current formulary, a list of participating primary care and specialty care providers, including disclosure of network arrangements that restrict access to providers within any plan network, please contact Customer Service at the number on the back of your identification card or 1 (800) 244-6224. You can also view participating providers and the formulary on the applicable links on this page.
The documents referred to in the medical coverage agreement can be obtained by contacting Customer Service at the number on the back of your identification number or 1 (800) 244-6224. You can also view the formulary and grievance policy by accessing the links on this page.
A full description of the procedures to be followed for consulting a provider other than the primary care provider and whether the primary care provider, the company's medical director, or another entity must authorize the referral can be obtained by contacting Customer Service at the number on the back of your identification number or 1 (800) 244-6224. You can also view authorization and referral information in your certificate.
General procedures that you must first follow for obtaining prior authorization for health care services can be located in the Benefit Summary above. You also obtain the full list of requirements by contacting Customer Service at the number on the back of your identification number or 1 (800) 244-6224.
Our reimbursement arrangements and provider compensation programs can be located at our provider directory at https://hcpdirectory.cigna.com/web/public/consumer/directory
If you want to request an annual accounting of all payments made by Cigna Healthcare which have been counted against any payment limitations, visit limitations, or other overall limitations on a person's coverage under a plan, please contact Customer Service at the number on the back of your identification card.
Accreditation status can be located at http://www.cigna.com/about-us/company-profile/accreditation
Referral procedures which include the procedures to be followed for consulting a provider other than the primary care provider, utilization review procedures for obtaining prior authorization, information on our formulary and other policies can be located at http://www.cigna.com/legal/members/member-rights-and-responsibilities/cigna-health-care-policies
Our drug list formulary can be located at https://www.cigna.com/individuals-families/member-guide/prescription-drug-lists/
Clinical preventive health care information can be located at https://www.cigna.com/knowledge-center/preventive-care
View our commitment to quality [PDF], including information on standardized measures of health care.
Our integrated plan to identify and manage the most prevalent diseases within its enrolled population, including cancer, heart disease, and stroke are included in its Case Management and Staying Healthy information are available at: https://www.cigna.com/health-care-providers/resources/patient-programs
Under Washington state law, a health care benefit manager (“HCBM”) is a person or entity providing services to, or acting on behalf of, a health carrier or employee benefits programs, that directly or indirectly impacts the determination or utilization of benefits for, or patient access to, health care services, drugs, and supplies including, but not limited to:
- (i) Prior authorization or preauthorization of benefits or care;
- (ii) Certification of benefits or care;
- (iii) Medical necessity determinations;
- (iv) Utilization review;
- (v) Benefit determinations;
- (vi) Claims processing and repricing for services and procedures;
- (vii) Outcome management;
- (viii) Provider credentialing and recredentialing;
- (ix) Payment or authorization of payment to providers and facilities for services or procedures;
- (x) Dispute resolution, grievances, or appeals relating to determinations or utilization of benefits;
- (xi) Provider network management; or
- (xii) Disease management.

An HCBM includes, but is not limited to, entities that specialize in specific types of health care benefit management such as pharmacy benefit managers, radiology benefit managers, laboratory benefit managers, and mental health benefit managers.

A list of HCBMs that are contracted with Cigna Healthcare is located at Washington Healthcare Benefit Managers [PDF]

Pharmacy Disclosure Requirements

"Does this plan limit or exclude certain drugs my health care provider may prescribe, or encourage substitutions for some drugs?"

Depending on a member's plan, generics may be used when filling the member's prescription for a brand drug, where available and appropriate, at the generic copay amount.
If a member's plan allows for doctor override, the member does not have to pay extra when receiving a brand name drug for which the doctor has specified "Dispense as Written" (DAW) on the prescription. The pharmacist dispenses the brand name drug specified in the prescription, not the generic alternative, and the member pays his or her cost share or copay for the brand name drug. If the doctor does not write DAW on the prescription for a brand name drug when a generic is available, and the member desires and requests the brand name drug, he or she will then have to pay the brand or generic copay plus the difference in cost between the brand and generic (up to the cost of the brand name drug).
Please contact Cigna Healthcare at the number on the back of your ID card for specific details or refer to your plan booklet for additional details.

"When can my plan change the approved drug list (formulary)? If a change occurs, will I have to pay more to use a drug I had been using?"

Maintaining our prescription drug list for the safety and health care needs of our members is the responsibility of the Pharmacy and Therapeutics Committee (P&T Committee). The P&T Committee reviews the drug lists at least annually and re-reviews existing drugs and drug classes when clinically significant data on safety and efficacy become available.
As circumstances warrant, we may add or remove medications from the prescription drug list from time to time. Generally, Cigna Healthcare limits its changes to the prescription drug list to a maximum of twice a year, unless safety issues warrant removal. Members using any medication targeted for removal from the preferred tier will receive written notification in advance of this change.
When a medication changes status from preferred to non-preferred or becomes non-formulary on our prescription drug list, we send targeted mailings to notify impacted members at least 90-days in advance of the scheduled prescription drug list status change. This allows members time to talk with their doctor and see if a lower-cost option might be right for them.

"What should I do if I want a change from limitations, exclusions, substitutions or cost increases for drugs specified in this plan?"

Please contact Cigna Healthcare at the number on the back of your ID card with any questions about your pharmacy plan.
"How much do I have to pay to get a prescription filled?"
- Our member website, myCigna.com, provides personalized pharmacy plan information and helpful tools including our Prescription Drug Price Quote Tool. The Prescription Drug Price Quote Tool shows members drug prices specific to their coverage plan and lets them search for pharmacies. The easy-to-use drug pricing tool enables members to quickly see their medication options and make smart health spending decisions. Members can:
- search for a drug and compare the cost of the brand-name medication and its generic equivalents
- view drug pricing at retail pharmacies and Cigna Healthcare Home Delivery Pharmacy in an easy-to-understand side-by-side format, including savings opportunities based on their coverage plan
- use the pharmacy search feature for in-network pharmacies
- get real-time drug price information and lower-cost drug options
- view pricing based on their specific pharmacy coverage, including deductibles, copays/coinsurance, and out-of-pocket limits
Prescription drug price quotes are also available by contacting Cigna Healthcare at the number on the back of your ID card.

"Do I have to use certain pharmacies to pay the least out of my own pocket under this health plan?"
- Cigna Healthcare provides a well-managed, quality network with national accessibility so our members can get prescription drugs at a convenient location near their home or work and while on vacation in the U.S. This network is actively monitored to determine optimal access through zip code analysis and member/client feedback. Our retail pharmacy network is composed of more than 68,000 pharmacies including:
- Major pharmacy chains
- Smaller regional chains
- Mass merchandiser pharmacies
- Grocery store pharmacies
- Veteran administration pharmacies
- Indian Tribal Unit pharmacies
- Independent pharmacies
Our network is large enough to provide members with convenient access to local participating pharmacies while providing competitive generic and brand drug discounts. Eighty percent of retail pharmacies are in our national pharmacy network.
Additionally, Cigna Healthcare owns and operates its own home delivery pharmacy—Cigna Healthcare Home Delivery Pharmacy.
Our member website, myCigna.com, provides personalized pharmacy plan information and helpful tools including our Prescription Drug Price Quote Tool. The Prescription Drug Price Quote Tool shows members drug prices specific to their coverage plan and lets them search for in-network pharmacies.
You can also obtain pharmacy information by contacting Cigna Healthcare at the number on the back of your ID card.

"How many days' supply of most medications can I get without paying another co-pay or other repeating charge?"

Depending on your pharmacy plan, you may be able fill your maintenance medication in a 90-day or 30-day supply at any pharmacy in your network. Maintenance medications are taken regularly, over time, to treat an ongoing health condition, such as diabetes, high blood pressure, cholesterol or asthma.
You may also have the opportunity to save money on copays by filling your prescriptions 90-days at a time.
Please contact Cigna Healthcare at the number on the back of your ID card with any questions about your pharmacy plan.

"What other pharmacy services does my health plan cover?"

Cigna Healthcare ensures members have 24-hour access to registered pharmacists for emergencies. As an added service to our members, most participating chain pharmacies provide 24-hour-store locations with a pharmacist available 24 hours each day. Members may call customer service toll-free or use myCigna.com to find the location of the nearest participating 24-hour pharmacy. Additionally, most pharmacies list emergency numbers on their doors and voice mail systems.
Depending on your pharmacy plan, we may also provide coaching teams and web/app services that offer members one view into their coverage and one research tool into their conditions.
Please contact Cigna Healthcare at the number on the back of your ID card with any questions about your pharmacy plan.

The Prescription Drug coverage provided by your plan uses the following provisions in the administration of coverage:

Exclusion of certain Prescription Drug Products from the Prescription Drug List;
Therapeutic drug substitution;
Incentives for use of generic drugs; such as step-therapy requirements and cost share incentives;
Precertification requirements;
Prescription Drug List changes;
Supply limit requirements; and
Specialty Prescription Drug Product requirements

Your certificate explains the process that you and your provider must use to seek coverage of a Prescription Drug Product that is not on the Prescription Drug List or is not the preferred Prescription Drug Product for a covered medical condition.

You may be eligible to receive an emergency fill for a Prescription Drug Product at a non-Network Pharmacy if Cigna Healthcare determines that the Prescription Order could not reasonably be filled at a Network Pharmacy. Your payment will be based on the Usual and Customary Charge submitted by the non-Network Pharmacy. You also may be eligible to receive an emergency fill for a Prescription Drug Product while a precertification request is being processed. The process for requesting this emergency fill and the cost share requirements for this emergency fill are described in your certificate.

Your certificate explains the process Cigna Healthcare uses for developing coverage standards and the Prescription Drug Lists.

Your certificate explains the process for changing coverage standards and the Prescription Drug Lists. Additionally, your certificate explains the process that you and your provider must use to seek coverage of a Prescription Drug Product that is not on the Prescription Drug List or is not the preferred Prescription Drug Product for a covered medical condition. The length of the authorization will depend on the diagnosis and Prescription Drug Product. There are instances when an approved Prescription Drug Product coverage exception may be grandfathered to allow ongoing coverage.

Coverage status of a Prescription Drug Product may change periodically. As a result of coverage changes the plan may require you to pay more or less for that Prescription Drug Product or try another covered Prescription Drug Product.

The Prescription Drug Product dispensing fee is considered to be a pharmacy-related service which is reimbursed by the plan.

Your certificate lists the categories of excluded Prescription Drug Products.

The above provisions are explained in your certificate, or you can contact Cigna Healthcare at 1 (800) 244-6224 for more information.

YOUR RIGHT TO SAFE AND EFFECTIVE PHARMACY SERVICES

State and federal laws establish standards to assure safe and effective pharmacy services, and to guarantee your right to know what drugs are covered under this plan and what coverage limitations are in your contract. If you would like more information about the drug coverage policies under this plan, or if you have a question or a concern about your pharmacy benefit, please contact us (the health carrier) at 1 (800) ‍244-6224.
If you would like to know more about your rights under the law, or if you think anything you received from this plan may not conform to the terms of your contract, you may contact the Washington State Office of Insurance Commissioner at 1 (800) 562-6900. If you have a concern about the pharmacists or pharmacies serving you, please call the State Department of Health at 1 (360) 236-4825.

Surprise Billing

If you have coverage under a Washington sitused plan and you receive a bill for out-of-network services rendered during an emergency or from an out-of-network provider at an in-network setting, state consumer protections may apply. Please contact Cigna Healthcare or the Washington state OIC for more information or if you believe you are being balanced billed.

Washington Balance Billing Protection Act/Federal No Surprises Act Consumer Notice [PDF]

If you have coverage under a West Virginia sitused plan and you receive a bill from an out-of-network provider at an in-network setting, state consumer protections may apply. Please contact Cigna Healthcare or WV DOI for more information or if you believe you are being balanced billed.

Network Access Plan

Cigna Health and Life Insurance Company-West Virginia Medical Network Access Plan [PDF]

Cigna Health and Life Insurance Company-West Virginia EyeMed Vision Network Access Plan [PDF]

Cigna West Virginia Dental HMO Network Access Plan [PDF]

Cigna West Virginia Dental PPO Network Access Plan [PDF]

Quarterly WV NADAC Report