Cy-Fair Open Access Plus (OAP) Plan

ONLY for use for mid-year "qualifying event" changes after July 1, 2006


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CY-FAIR I.S.D. Open Access Plus Plan Premiums
Effective for Plan Year May 1, 2008


CY-FAIR I.S.D. OAP Plan Monthly Premium Rates - Note increased rates; new plan benefits
 
Monthly Rates Full-Time
(7+ hours a day)		 Part-Time
(3-6 hours a day)
     
Employee Only $ 120.00 $ 120.00
(same as for full-time)
Employee & Child(ren) $ 260.00 $ 332.00
Employee & Spouse $ 370.00 $ 443.00
Employee & Family $ 630.00 $ 748.00
     
     
 
     
     
YOUR CIGNA PPO BENEFITS

PREVENTIVE CARE

Our goal is to keep you healthy. Our preventive care benefits help uncover potential problems before they affect your health. See the Summery of Benefits inside for specific preventive care coverages.

EMERGENCY CARE

Don't worry. No matter where you travel in the U.S. or worldwide, you are covered for emergency care.

CHOICE OF DOCTORS

You can use any "preferred provider" in our network without a referral. See the listing of participating doctors at Cigna.com. Or, when you wish, you can go out of network.

OUT OF NETWORK COVERAGE

You're still covered when you go out of network, but your costs will be higher. No referrals are needed however, you'll have to pay for services received and file a claim for reimbursement.

HOSPITALIZATION

Your costs will be lower when you use a hospital in our network and your stay has been pre-approved.

CIGNA's TOLL FREE CARE LINE

Call for assistance in finding a preferred provider, or for steps to take before admittance to a hospital. Call CIGNA Careline at 1-800-251-0669 for further information.

NO CLAIMS OR OTHER PAPERWORK

In the network, just show your CIGNA ID card and pay the small fee for the visit. There's no paperwork hassle. Cypress-Fairbanks ISD's PPO group number is 3200120.
 
 
Cy-Fair I.S.D. PPO (CIGNA)
 
Medical Expense Benefit Provisions

Co-insurance is applied after deductible is met and counts toward the annual out-of-pocket maximums.

Co-payments are not subject to deductibles and are not credited toward deductibles and out-of-pocket maximums.

The non-surgical office visit copay applies to most services provided in the course of an office visit (i.e. examinations, lab/x-ray tests and injections). One co-payment applies per office visit regardless of the number of conditions treated/examined. Certain expenses are excluded from the office visit copayment benefit. Some examples of these are: drugs and medications not administered in the office, surgery, and lab/x-ray expenses billed by a freestanding independent laboratory.

Deductible Explanation: The "Common Deductible" is actually applicable to all covered charges except In-network, non-surgical office visits and In-network prescription drugs. The Out-of-Network deductible is applicable after the Common Deductible has been satisfied for additional charges incurred for services from Out-of Network providers.

Additional Provisions:

  • The plan provides benefits for medically necessary services. (Routine "well care" for dependent infants and children including routine immunizations, is a covered expense under the plan.) Routine physical exams and immunizations for covered adults are also covered under the plan.
  • Pregnancy is covered the same as any other illness.
  • Unmarried dependent children are eligible for coverage to age 25, regardless of their student status.
  • Unmarried, dependent grandchildren are eligible for coverage and, once covered, retain their eligibility for coverage to age 25, regardless of their student or dependency status.
  • The Out-of-Pocket Maximum does not include the In-network non-surgical office visits, In-network prescription drugs, non-PPO hospital per confinement deductible, the Medical Management non-notification deductible, or out-of-pocket expenses incurred for the treatment of mental and nervous and substance abuse conditions.
  • In PPO and Out-of-PPO charges that satisfy out-of-pocket maximums are separate and mutually exclusive of each other.
  • All deductibles and annual out-of-pocket maximums accumulate in one direction, toward
    in-network.
  • The plan provides benefits for medically necessary services. (Routine "well care" for dependent infants and children including routine immunizations, is a covered expense under the plan.) Routine physical exams and immunizations for covered adults are also covered under the plan.
  • Pregnancy is covered the same as any other illness.
  • Unmarried dependent children are eligible for coverage to age 25, regardless of their student status.
Prescription Drug Benefits

Prescription drug benefits are provided through PTRx. Go to " RX Prescription Coverage" (link) for information.

Exclusions:
  • The plan does not cover charges for treatment received for occupational-related injury and illness.
  • The plan does not cover charges for treatment received before a member becomes insured under the plan.
  • The plan provides benefits for active employees and their eligible dependents unless otherwise noted in the Insurance Contract.
  • The plan does not cover charges for unnecessary medical treatment.
  • The plan does not cover charges for custodian care.
  • The plans do not cover charges for eye infraction, eyeglasses or hearing aids, except on account of accidental injury while insured, including related testing (includes an exclusion for Radial Keratotomy.)
 
Cigna HealthCare
P.O. BOX 182223
CHATTANOOGA, TN 37422-7223

www.cigna.com

Group Number 3200120
Customer Service: 1-800-244-6224

Prescription Drug Benefit
Provided by PTRx

www.ptrx.com

Group Number: CFISDRX
Customer Service: 1-877-469-7879
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