SCHEDULE OF COVERAGE
CATASTROPHIC (CAT) PLAN
CITY OF LEWISVILLE
Plan Benefits Effective: October 1, 2007
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.
*After deductible has been met
Dependent children are covered to age 19, or to age 25 if a full-time student.
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 DRUG BENEFITS | |||
 | Participating Pharmacy | Mail Order Prescription | |
Brand Name Drugs | 30% of the actual cost up to $150 maximum per 30-day supply | 25% of actual cost up to $300 maximum per 90-day supply | |
Generic Drugs | 10% of the actual cost per 30-day supply | 10% of actual cost per 90-day supply | |
VISION CARE BENEFITS | |
Type of Service | Benefits |
| $50 per Exam |
| $35 per pair $50 per pair $60 per pair $100 per pair |
| $100 per Calendar Year |
| $75 per Calendar Year |
Both Contact Lenses and Eyeglasses (Frames and Lenses) not allowed in same Calendar Year.
