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SCHEDULE OF COVERAGE

CATASTROPHIC (CAT) PLAN

CITY OF LEWISVILLE

Plan Benefits Effective: October 1, 2010


Customer Service (800) 244-6224
This schedule represents a summary of benefits. For complete details of benefits and requirements please refer to the Medical Benefits Booklet.
The Plan pays a higher benefit for eligible expenses for charges incurred through a Network provider. Consult your Provider Directory or Provider web page at www.cigna.com or call CIGNA at (800) 244-6224 to locate the provider nearest you.


Benefits
In-Network
Out-of-Network
Preventive Care Maximum
unlimited
Deductible (does not apply to OOP Max)
Per Plan Year
Individual
$5,000
$10,000
Family
$10,000
$20,000
Coinsurance
80%*
50%*
Out-of-Pocket Maximum (excludes deductible)
Individual
$5,000
$10,000
Family limit
$10,000
$20,000
Hospital Services
Inpatient1
80%*
50%*
Surgical Services (any setting)
80%*
50%*
Physician Services
Primary Care Office Visits
Specialist Office Visits
All Other Services
80%*
80%*
80%*
50%*
50%*
50%*
Urgent Care
80%*
50%*
Emergency Room
80%*
50%*
Accidents & Medical Emergency (within 48 hours)
Inpatient Visits
Physician’s Office
80%*
80%*
Lab in Outpatient Setting (Non Preventive)
80%*
50%*
X-Ray in Outpatient Setting (Non Preventive)
80%*
50%*
Advanced Radiology Imaging (MRI, MRA, CAT, PET, etc.)
80%*
50%*
Preventive Care2
    Routine Physicals
    Lab & X-ray
    Hearing Exams
100%
50%*
Immunizations2
100%
50%*
Newborn Inpatient Care
80%*
50%*
Hearing Aids ($1,000 lifetime maximum)
80%*
Skilled Nursing Facility1,3 (90 days per plan year)
80%*
50%*
Home Health Care1,3 (120 visits per plan year)
80%*
50%*
Hospice Care1,3
80%*
50%*
Ambulance
$5,000 plan year maximum
80%*
Outpatient Short-Term Rehab
    Speech Therapy
80%*
50%*
    Physical Therapy
80%*
50%*
    Occupational Therapy
80%*
50%*
Home Infusion Therapy1
80%*
50%*
External Prosthetic Appliances
80%*
50%*
Chiropractic Services
80%*
50%*
Mental Health Services/Chemical Dependency 1,4
    Hospital Inpatient
80%*
0%
Outpatient
80%*
0%
    Serious Mental Illness1,4
80%*
0%
All Other Services
80%*
50%*
*After deductible (please note: non-network charges are considered based on usual and customary rates prevailing in the geograph

Dependent children are covered to age 26.

Preexisting Conditions: Services/Supplies for the treatment of a Preexisting Condition will be covered up to a $2,000 maximum dollar amount for the first 18 months from the Participant’s effective date of coverage. All new participants who enroll in the Plan are required to meet the Preexisting Condition waiting period.

Mental Health/Chemical Dependency treatment must be preauthorized. Please contact the EAP provider for preauthorization: Interface (800) 324-4327.


Prescription Benefits
Retail (Participating Pharmacy) Mail order through Tel-Drug
(Limited to a 30-day supply)(Limited to a 90-day supply)
Generic10% of the actual cost10% of the actual cost
Brand Name30% of the actual cost, up to $150 maximum per prescription25% of the actual cost, up to $300 maximum per prescription

Vision Care Benefits
Benefits
Reimbursement Amount
Eye Exam (Once each plan year)
$50
Pair of Lenses (Each plan year)
        § Single vision
        § Bifocal
        § Trifocal
        § Lenticular
$35
$50
$60
$100
Frames (Each plan year)
$75
Contact Lenses (In Lieu of Eyeglasses/Each plan year)
$100


Both Contact Lenses and Eyeglasses (Frames and Lenses) not allowed in same Plan Year.
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