591795 p 11/13 QUICK gUIde to CIgna Id Cards

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RUN_DATE DATA_SEQ_NO CLIENT_NUMBER UHG_TYPE DOC_ID DOC_SEQ_ID NAME MAILSET_NUMBER CUST_KEY1 CUST_KEY2 CUST_KEY3 CUST_KEY4 CUST_KEY5 CUST_KEY6 Doe 9116687/000001-00 9116687/000001-01 9116687/000001-02 20130314 DIG1CARD 00699998 100000008 John Doe 0000001 003040 0000001 05:58:28 ,John RUN_DATE DATA_SEQ_NO CLIENT_NUMBER UHG_TYPE DOC_ID DOC_SEQ_ID NAME MAILSET_NUMBER CUST_KEY1 CUST_KEY2 CUST_KEY3 CUST_KEY4 CUST_KEY5 CUST_KEY6 Doe 9116687/000001-00 9116687/000001-01 9116687/000001-02 20130314 DIG1CARD 00699998 100000008 John Doe 0000001 003040 0000001 05:58:28 ,John Primary Care $30 Specialist $40 Urgent Care $65 Preventive Care $20 PCP: None Selected No Referral Required For plan & benefit details, please visit myCIGNAforhealth.com Plan Contractor: Connecticut General Life Insurance Company Members and Providers Call 1-866-494-2111 GWH-Cigna Plans 03040 9116687 0000 0000001 0000001 072 7117 03040 9116687 0000 0000001 0000001 072 7117 XYZ Company RXBIN 600428 10 RXPCN 05180000 Issuer 80840 Group Plan 123456789 John Public ID 123456789 01 1 COPAY: Primary Care $30 4 Specialist $40 Urgent Care $65 ER $200 PCP: None Selected No Referral Required 8 >000001 9116687 001 003040 >000001 9116687 001 003040 For plan & benefit details, please visit myCIGNAforhealth.com • PCP selection encouraged • No referrals required • GWH-Cigna ID cards represent all products Cigna Health Cigna and Health Life Insurance and LifeCompany Insurance Company GWH-Cigna GWH-CIGNA Plan Type Open Plan Access Type Plus Submit All Claims To 1000 Great-West Drive Kennett, MO 63857-3749 Payer ID #62308 Members and Providers Call 1-866-494-2111 Group 00699998 Group 00699998 Issuer (80840) Issuer (80840) ID 100000008 ID 100000008 1 Copays Copays 4 Name JohnName Doe John Doe Primary Care Primary $25 Care $25 PCP NonePCP Selected None Selected Specialist $25 No Referral Required 8 Specialist $25 No Referral Required Urgent Care $100 Urgent Care $100 ER $200 XYZ Sample XYZ CompanyHoldings Sample CompanyHoldings Co. ER $200 Co. 11 10 RxBIN 600428 RxPCN 05180000 RxGrp 00688888 RxBIN 600428 RxPCN 05180000 RxGrp 00688888 RxID 100000008 RxID 100000008 00 00 5 13 12 14 9 12 13 14 9 Members: Carry this card at all times. Pretreatment authorization must be obtained for hospital admissions, outpatient surgeries performed outside a physician’s office and for the other services specified in the benefit plan. Member is responsible for obtaining authorization for non-network services. Failure to follow pretreatment authorization procedures may result in a reduction of benefits. In an emergency, seek care immediately, then call your primary care doctor as soon as possible for further assistance. We encourage you to use a primary care physician as a valuable resource and personal health advocate. CIGNA has multiple networks. Your plan is paired with the GWH-CIGNA network. To find a GWH-CIGNA provider, please visit your member website at myCIGNAforhealth.com. Providers: Pretreatment authorization must be received for all services listed above and as specified in the member’s benefit plan by calling the number on the front of this card or online at CignaforHCP. com. Emergency hospital admissions must be reported within 48 hours. Notice: Possession of this card does not guarantee coverage or payment for the service or procedure reviewed. Please call the Member and Providers number on the front of this card for eligibility information. For providers not in your primary network, visit multiplan.com For Pharmacists Only 1-800-XXX-XXXX What doesit mean? What doesit mean? R318 (5/10) Mask 401 Your share of the payment for health care services may be based upon our agreement withyour provider. Your provider may billyou for amounts up to the provider's regular billed charges. *117* *117* 'Cigna' is aregistered service mark, and the 'Tree of Life' isaservice mark, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or throughsuch operating subsidiaries and not by Cigna Your share of the payment for health care services may be based Corporation. Such operating subsidiaries include Connecticut General upon our agreement withyour provider. Your provider may billyou Life Insurance Company, Cigna Health and Life Insurance Company, Cigna for amounts up to the provider's regular billed charges. Health Management, Inc. and Cigna Dental Health, Inc. The Cigna Dental PPO is underwritten or administered by Connecticut General LIfe Insurance Issue Date: 01/01/12 Company 'Cigna' is aregistered orCigna Health service and mark, Life Insurance and the 'Tree Company of Life' with isaservice network management mark, of Cigna services Intellectual provided Property, by Cigna Inc., Dental licensed Health, for use Inc., by and Cigna certain of Corporation its operating and subsidiaries. its operating subsidiaries. All products and services are provided by or throughsuch operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, Cigna Health Management, Inc. and Cigna Dental Health, Inc. The Cigna Dental PPO is underwritten or administered by Connecticut General LIfe Insurance Company orCigna Health and Life Insurance Company with network management services provided by Cigna Dental Health, Inc., and certain of its operating subsidiaries. Send All Claims To Send 1000 All Great-West Claims To Drive 1000 Kennett, Great-West MO63857-3749 Drive Kennett, Payer MO63857-3749 ID #62308 Payer ID #62308 Customers &Health Care Professionals call 1-866-494-2111 Rx Claims: Pharmacy Customers Service Center, &Health PO Box 3598, Care Scranton Professionals PA 18505-0598call 1-866-494-2111 Rx Claims: For Pharmacy Pharmacists Service Only Center, 800-351-9170 PO Box 3598, Scranton PA 18505-0598 For Pharmacists Only 800-351-9170 Mask 601 Issue Date: 03/14/13 Mask 601 Issue Date: 03/14/13 Global Health Benefits • PCP selection encouraged • No referrals required • GWH-Cigna ID cards represent all products 00000000 00000000 DIRECT USPS DIRECT USPS John Doe 888 N Main JohnSt Doe Olympia, 888 WA N98502 Main St Olympia, WA 98502 10 1 20130313 20130313 Thu Mar 14, 2013 @ 05:58:28 N Thu Mar 14, 2013 @ 05:58:28 601 N 601 • PCP selection encouraged • Patients in these Cigna-administered plans use Cigna PPO or Cigna OAP networks in the U.S., as indicated on the back of the card • Network Savings Program logo on back of card indicates out-of-network discounts may apply 12 14 13 9 15 1
Shared Administration (SAR) Cigna Choice Fund ® OA Plans Shared Administration PPO Shared Administration OAP TPV logo Legal entity name Coverage effective date: MM/DD/CCYY 7 Choice Fund Open Access Plus Group: 1234567 No referral required Issuer (80840) PCP Visit 15%/20% Specialist 3 15%/20% ID: U23456789 01 1 Hospital ER 20% Name: John Public Vision Yes PCP: John Smith Rx 30%/40%/50% PCP Name Ln2 8 Network Coinsurance: In 90%/10% PCP Phone: XXX.XXX.XXXX Out 70%/30% ID card acct name 10 NSP Med/Rx deductible applies RxBIN 600428 RxPCN 02150000 logo 9 DOI Network Savings Program 850702 • PCP selection encouraged • Cigna Choice Fund® and medical plan type indicated • Most coinsurance information shown • Coinsurance/deductible is paid directly to the doctor/facility by Cigna using patient’s available health funds. Explanation of Payment (EOP) will show any remaining amount due from patient TPV logo • Cigna Care Network is available CSN logo Cigna Care Network Legal entity name Coverage effective date: MM/DD/CCYY Group: 1234567 Issuer (80840) ID: U23456789 01 1 Name: John Public S 16 This plan is self-funded by: ID card account name Fund #: SAR F RxBIN Rx Bin RxPCN 02150000 DOI TPV logo 11 11 Legal entity name Coverage effective date: MM/DD/CCYY Group: 1234567 Issuer (80840) ID: U23456789 01 1 Name: John Public S 16 PCP: James Smith PCP name Ln2 PCP phone: 860-555-1212 Fund Name Fund #: Fund number RxBIN 600428 RxPCN 02150000 DOI • PCP selection encouraged • No referrals required • Cigna Care Network is available 5 5 11 5 7 7 18 6 Client logo Provider network: Cigna HealthCare PPO Doctor visit $10 4 Specialist $20 Coinsurance 3 In-network 90% / 10% Out-of-network 70% / 30% Rx 30% / 40% / 50% Deductible applies Client logo Client logo Open Access Plus No referral required 4 Cat# PCP visit $15 Specialist $20 Rx 30% / 40% / 50% Network coinsurance: 3 In 90% / 10% Out 70% / 30% Deductible applies Cat# 12 13 WWW.CIGNA.COM You may be asked to present this card when you receive care. The card does not guarantee coverage. You must comply with all terms and conditions of the plan. Willful misuse of this card is considered fraud. INPATIENT ADMISSION: Your provider must call the toll-free number listed below to pre-certify the above services. Refer to your plan documents for your pre-certification requirements. Failure to do so may affect benefits. In an emergency, seek care immediately, then call your primary care doctor as soon as possible for further assistance and directions on follow-up care within ### hours. Coinsurance/deductible is paid directly to the doctor/facility by Cigna using individual’s available health funds. For Pharmacy, call ABC Company 1.800.XXX.XXXX (Not a Cigna Company) For Vision, call ABC Company 1.800.XXX.XXXX (Not a Cigna Company) Send claims to: CAD Name, PO Box XXXX, Anytown, USA 12345-6789 TPV Name, PO Box XXXX, Anytown, USA 12345-6789 All Others: PO Box XXXX, Anytown, USA 12345-6789 Customer Service: 1.800.XXX.XXXX 14 16 MH/SA: 1.800.XXX.XXXX We encourage you to use a PCP as a valuable resource and personal health advocate. AWAY FROM HOME CARE • Coinsurance/deductible should not be collected at the time of service unless you have accessed the Cigna Cost of Care Estimator®on the Cigna for Heath Care Professionals website (Cignaforhcp.com) to obtain an estimate of the patient’s costs, and provide a copy of the estimate to the patient • Collecting at the time of service without accessing the Cigna Cost of Care Estimator may result in overpayment and require a refund to the patient You may be asked to present this card when you receive care. The card does not guarantee coverage. You must comply with all terms and conditions of the plan. Willful misuse of this card is considered fraud. 12 INPATIENT ADMISSION: Your provider must call the toll-free number listed below to pre-certify your medical services or benefits may be affected. Refer to your plan documents for your plan’s precertification requirements. In an emergency, seek care immediately, then notify Cigna within 48 hours. Mail all non-medical claims and correspondence to: ID card name back SAR fund name 13 Submit/mail claims to: Cigna Payor 62308, PO Box 188004, Chattanooga, TN 37422-8004 All other: TPV N&A print line Pre-certification: Member Srvc Nu Pharmacy Questions: 1.800.244.6224 Eligibility, Benefit and Claim questions please call: SAR TPA phone 14 To access the online provider directory go to www.CignaSharedAdministration.com To access member pharmacy tools go to www.myCigna.com 15 AWAY FROM HOME CARE Benefits are not insured by Cigna HealthCare 17 12 You may be asked to present this card when you receive care. The card does not guarantee coverage. You must comply with all terms and conditions of the plan. Willful misuse of this card is considered fraud. INPATIENT ADMISSION: Your network provider must call the toll-free number listed below to pre-certify the above services. Refer to your plan documents for your pre-certification requirements. Failure to do so may affect benefits. In an emergency, seek care immediately, then call your primary care doctor as soon as possible for further assistance and directions on follow-up care within ### hours. Mail all non-medical claims and correspondence to: Fund name Fund address Send claims to: Claims address 13 All others: PO Box XXXX, Anytown, USA 12345-6789 Pre-certification: Member Srvc Nu Pharmacy Questions: Pharm Num Eligibility, Benefit and Claim Questions: Please call Payor Num 14 To access the online provider directory go to www.cignasharedadministration.com To access member pharmacy tools go to www.mycigna.com We encourage you to use a PCP as a valuable resource and personal health advocate. AWAY FROM HOME CARE 15 17 2
Page 1 and 2: 2013 QUICK guide to Cigna ID cards
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591795 p 11/13 QUICK gUIde to CIgna Id Cards

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