Download GUIDE TO MEDICAL AND DENTAL PLANS

GUIDE TO MEDICAL AND DENTAL PLANS
Benefits effective July 1, 2015 through June 30, 2016
Choosing your benefits is an important decision. This guide provides you with the information that will help you make an
informed choice about your medical and dental coverage for the coming year. The options you choose will remain in effect
from through June 30, 2016. Each spring, you have an opportunity to review your choices and make any changes you may need
for the next plan year.
Your Medical Plan Options:
 For the Open Access Plus Plan, in-network, and for the Network Plan, the plan pays the percentages shown in the chart
below of covered contracted amounts.
 For the Open Access Plus Plan, out-of-network, the plan pays the percentages shown in the chart below of reasonable
and customary charges.*
 You pay any copay amount, your coinsurance amount, and, for Open Access Plus, any out-of-network charges above
reasonable and customary charges.
* Reasonable and customary rates are used industry wide and are determined by the average range of charges made by most physicians,
hospitals and other providers of care in the same geographical area.
MEDICAL PLAN OPTIONS
Benefit Feature
Plan Deductible
(Per covered family member)

Employee Only

Employee + Dependent

Employee + Family
Plan Out-of-pocket Limit
(per covered family member; includes
deductible)

Employee Only

Employee + Dependent

Employee + Family
Lifetime Maximum Benefits
Open Access Plus Plan
In-network
Out-of-network
$500
$1,000
$1,000 (maximum)
$700
$1,400
$1,400 (maximum)
Network Plan
In-network only
None
$1,800
$3,600
$3,600
$7,200
$3,600 (maximum)
$7,200 (maximum)
Unlimited
Hospital – inpatient and outpatient
85% after deductible
65% after deductible
Surgeon’s Charges
Doctor’s Visits

Primary Care Physician Visit

Specialist Visit
85% after deductible
65% after deductible
Unlimited
100% after $250 copay – inpatient
100% after $100 copay – outpatient
100%
100% after $25 copay
100% after $40 copay
65% after deductible
65% after deductible
100% after $25 copay
100% after $40 copay
Note: Open Access Plus reimbursement
as an office visit or outpatient facility
visit depends on the provider’s billing
procedures and administration.
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MEDICAL PLAN OPTIONS continued…
Benefit Feature
Open Access Plus Plan
In-network
Precertification and Review
Required for inpatient care and
outpatient procedures
Out-of-network
Coordinated by Provider
Patient is responsible for
contacting CIGNA prior to
obtaining inpatient care or
outpatient procedures.
Network Plan
In-network only
Coordinated by Provider
Failure to call CIGNA will
result in a 50% reduction in
benefits payable.
X-ray and Lab (including diagnostic
testing)
Preventive Services
as determined by your doctor,
including:

Preventive Physical Exams

Well Woman Exams,
including related tests at
physician’s office

Screening Tests, such as
diabetes and cholesterol tests

Well Child Care
2
Immunizations
Mammograms, PSA, PAP Smear,
Colonoscopy

Preventive

Diagnostic
3
Maternity Care

Pre & Post Natal Exams

Delivery - Facility Charge

Delivery – Surgeon
Emergency Hospital Care
Skilled Nursing Facility,
Rehabilitation Hospital and Subacute Facilities
(semi - private room)
Home Health Care
Durable Medical Equipment
External Prosthetic
Appliances
Second Surgical Opinion
Claim forms
Pre-existing Condition
1
1
65% after deductible
100%
100% (no deductible)
65% after deductible
100%
100%
65% after deductible
100%
100%
85% after deductible
65% after deductible
65% after deductible
100%
100%
4
65% after deductible
65% after deductible
65%after deductible
100%
100% after $250 copay
100%
85% after deductible
85% after deductible
85% after deductible
85% after deductible
85% after deductible
85% after deductible
65% after deductible
(120 days combined maximum per plan year)
85% after deductible
(120 visits per plan year)
85% after deductible
65% after deductible
(120 visits per plan year)
65% after deductible
85% after deductible
65% after deductible
Voluntary, no charge; deductible waived
Not required
Required
No pre-existing condition
limit applies.
3
100% after $100 copay
(waived if admitted)
100%
(60 days combined maximum
per plan year)
100%
100%; no maximum.
100% after $200 per plan year
deductible
Voluntary, no charge; requires
referral from PCP
Not required
No pre-existing condition
limit applies.
If part of a physician’s office visit, 100% after PCP or specialist copay.
Includes travel vaccines for Typhoid, Yellow Fever, Cholera, Plague, Japanese Encephalitis, and Japanese Encephalitis virus vaccine. Exclusions
may apply for other travel immunizations.
3
Includes the rental of one breast pump per birth as ordered /prescribed by a physician and related supplies.
4
For the initial office visit to confirm pregnancy, plan pays 100% after PCP or specialist copay.
2
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MEDICAL PLAN OPTIONS continued…
Open Access Plus Plan
Benefit Feature
In-network
Mental Illness & Substance Abuse
Services
Annual Deductible
Deductible Combined with Medical
Benefits
Lifetime Maximum Benefits
Inpatient Care
Out-of-network
Network Plan
In-network only
Benefits same as any other illness
$500 Individual
$1,000 Family maximum
$700 Individual
$1,400 Family maximum
None
No maximum
No maximum
No maximum
85% after deductible
65% after deductible
100% after $250 copay
100% after $25 copay
85% after deductible
65% after deductible
65% after deductible
100% after $25 copay
100%
Outpatient Care
Individual therapy, group therapy
(mental health only) and intensive
outpatient services


Physician’s office visit
Outpatient facility
Pre-certification and Review
Required for inpatient care and
outpatient procedures
Coordinated by Provider
Patient is responsible for
contacting CIGNA prior to
obtaining inpatient care or
outpatient procedures.
Coordinated by Provider
Failure to call CIGNA will
result in a 50% reduction in
benefits payable.
VISION BENEFITS
If you participate in the Network Plan, you receive modest vision benefits at no additional cost to you. These benefits are
being administered separately by Cigna. A summary of these benefits and information on finding network vision providers is
available on the Human Resources website (see the Cigna summary of vision benefits for Network Plan participants) or by
contacting Human Resources Benefits by phone (312.629.3371) or email ([email protected]).
There are no vision benefits in the Open Access Plus Plan.
All employees, even those who receive vision benefits through enrollment in the Network Plan, may enroll in the EyeMed
Vision Plan. A summary of these benefits is available on the Human Resources website (see the EyeMed Vision Plan
summary) or by contacting Human Resources Benefits by phone (312.629.3371) or email ([email protected]).
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Important
The Open Access Plus Plan and Network Plan will pay benefits only for treatment that is medically necessary, unless it is
specifically named as a covered service. Neither the Open Access Plus Plan nor the Network Plan will pay benefits for the
following:








Medically unnecessary supplies, care, treatment, or surgery
Expenses for or in connection with a work-related injury
Any procedure or treatment that is deemed to be experimental, investigational or unproven
Hearing aids
Routine foot care
Massage therapy
Acupuncture (unless medically necessary, up to 15 visits per condition)
Cosmetic surgery and therapies
Note: This is not a complete list of all covered services and exclusions. See your Summary Plan Description for a more
detailed list or call CIGNA at 800.CIGNA24.
PRESCRIPTION DRUG BENEFITS
When you enroll in one of the medical plan options, you automatically receive prescription drug benefits through Express
Scripts. There is no deductible to meet for prescription drugs. To view the list of preferred (also referred to as formulary)
brand name drugs, visit the www.express-scripts.com.
Both Open Access Plus and Network Plans
Prescription Drugs
Retail (not to exceed a 30-day supply)

Generic Drugs

Preferred Brand Drugs

Non-preferred Brand Drugs
Participating pharmacy
Non-participating pharmacy*
100% after $10 copay
100% after $30 copay
100% after $50 copay
50% after $10 copay
50% after $30 copay
50% after $50 copay
If your doctor approves a generic drug and you choose instead to buy the brand name
drug, you will also pay the difference between the price of the drug you choose and the
generic equivalent.
Mail Order (up to a 90-day supply)

Generic Drugs

Preferred Brand Drugs

Non-preferred Brand Drugs
100% after $20 copay
100% after $60 copay
100% after $100 copay
* The plan pays 50% of the amount a participating pharmacy would charge after the copay.
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DENTAL BENEFIT OPTIONS
Dental PPO 1
Benefit Feature
Dental HMO
In-network
Out-of-network
$50
$100
$150 (maximum)
$100
$200
$300 (maximum)
2
Plan Deductible
(per covered family member)

Employee Only

Employee + Dependent

Employee + Family
Annual Maximum Benefit
$1,500 per person
$0
$0
$0
None
Diagnostic/Preventive



Oral Exams (limits apply)
Routine Cleanings
(limits apply)
X-rays (limits apply)
Basic Restorative

Fillings

Extractions

Root Canal Therapy

Oral Surgery

Periodontics
Major Restorative

Full and Partial Dentures

Crowns and Bridges

Implant

Implant Prosthetic
100%
100%
80% after deductible
60% after deductible
50% after deductible
Orthodontia

Children & Adults
Claim Forms
Emergency Care
40% after deductible
100%
Various copays
(see patient charge schedule
available on the Human
Resources Web site
or from Human
Resources—Benefits).
Not Covered
Not required
Required
Not required
100%
100%
$66 patient charge for office visit after
regularly scheduled hours
In area: Contact Dental HMO personal dentist or
call 1.800.CIGNA24.
Out of area: Seek treatment from any dentist.
Contact Cigna Dental HMO regarding possible
reimbursement.
1
Under the Dental PPO option, benefits for out-of-network services are based on reasonable and customary charges. Amounts determined
to be above reasonable and customary are not eligible for coverage.
2
A deductible does not apply to charges reimbursed at 100%.
This Guide provides a description of the benefit programs that are effective July 1, 2015 – June 30, 2016 for eligible
employees of the Art Institute of Chicago. Plan provisions are described in more detail in other communications and are
governed by the actual plan documents. The Art Institute of Chicago reserves the right to terminate or change benefit plans
at any time, and has sole discretion to interpret the plans to determine eligibility for participation and benefits.
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TERMS YOU SHOULD KNOW
ANNUAL DEDUCTIBLE
1
The amount of covered expenses that
you must pay each year before your
plan begins paying benefits. Each
covered person in your family has a
separate annual deductible. The most
you can be charged, however, is the
family deductible amount.
ANNUAL OUT-OF-POCKET
1
LIMIT
The maximum you are required to
pay in any plan year for eligible
medical expenses, including
deductibles and coinsurance. Once
you reach the annual out-of-pocket
limit, your medical plan pays 100%
of all covered, eligible charges
through the end of the plan year.
Note: Copays, non-compliance
penalties, and charges in excess of
reasonable and customary charges do
not count towards meeting the
out-of-pocket limit. In addition, you
continue to pay these expenses after
you meet the out-of-pocket limit.
EXPLANATION OF
BENEFITS (EOB)
An Explanation of Benefits, or
“EOB,” is the statement you receive
after you file a claim with an insurance
carrier or a claim has been filed on
your behalf by the doctor. This
statement is a summary of the action
taken on your claim—how much of the
bill was paid by the insurance carrier
and how much is your responsibility
to pay (you may already have paid
that portion at the time of service).
You do not receive EOBs for the
Network Plan or the Dental HMO.
INPATIENT HOSPITAL/OUTPATIENT
PROCEDURES PRECERTIFICATION
For out-of-network services under the
Open Access Plus Plan, advance
notice to CIGNA for admissions and
services that require approval prior
to when services are obtained. Failure
to obtain precertification results in a
reduction of benefits payable.
PREFERRED BRAND
A list of prescription drugs
determined by the prescription
drug management company to be
among the best options for treating
a particular condition in terms of
effectiveness and cost.
PRIMARY CARE
PHYSICIAN (PCP) - NetworkPlan
For Network Plan participants, the
primary doctor who provides basic
medical care and referrals to
specialists. Each family member
may have a different PCP. For a child,
you may designate a pediatrician
as the PCP. You do not need prior
authorization from your PCP to obtain
access to obstetrical or gynecological
care but you must use a Network
provider. You may change your PCP at
any time during the year by calling CIGNA
at 800.CIGNA24 or by logging on to my
CIGNA.com.
COINSURANCE
The portion of a covered expense that
you pay after the plan pays its portion
and after you’ve met the deductible.
COPAY
The fixed dollar amount you pay for
prescriptions and services, such as
doctor office visits.
1
For Open Access Plus, deductibles and out-of-pocket limits cross-accumulate between in- and out-of-network.
Copays do not count toward the deductible.
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