591795 p 11/13 QUICK gUIde to CIgna Id Cards

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2012 Starbridge - CIGNA HealthCare PPO 2012 Starbridge - CIGNA HealthCare PPO Primary Network: CIGNA Primary HealthCare Network: PPO CIGNA HealthCare PPO Secondary Network: Beech Secondary TPV Street / Alliance Network: Beech Street Connecticut TPV / Alliance General Connecticut Life Insurance LogoGeneral Company Life Insurance Company Logo www.starbridge.com Primary Network: CIGNA HealthCare PPODoctor Visit Doctor $25 Visit $25 Coverage Effective Date: Coverage 00/00/0000 Effective Date: 00/00/0000 Secondary Network: Beech Street Specialist 7 www.starbridge.com Specialist $25 $25 4 Primary Network: CIGNA HealthCare PPO Secondary ID: AMI Network: Beech ID: Connecticut Street AMIGeneral Life Insurance Company Network Coinsurance: Network Coinsurance: Connecticut General Life Insurance Company In Name: Doctor In Visit 80%/20% $25 80%/20% Name: Name Coverage Name Effective Date: 00/00/0000 Out Doctor Visit Specialist Out $25 SM80%/20% 3 SM $25 80%/20% Coverage Effective Date: 00/00/0000 Account Number: Account ID: 2466518 AMI Number: 2466518 Specialist Network $25 Coinsurance: ID: AMI Network Coinsurance: In 80%/20% Name: Name Group Name: In Out 80%/20% SM 80%/20% Name: Group Name: Group Number: Group Out Account Number: Number: 2466518 SM 80%/20% Account Number: 2466518 Fundamental Care TPV / Alliance Logo Group Name: Group Number: TPV / Alliance Logo 11 Group Name: A V I A N T N E T W O A R K V I A N T N E T W O R K Group Number: • No PCP selection required A V I A N T N E T W O R K • No referrals required • In-network and out-of-network coverage 2012 FundamentalCare 2012 FundamentalCare - CIGNA - HealthCare CIGNA HealthCare PPO PPO 5 A V I A N T N E T W O R K www.fundamentalcare.com www.fundamentalcare.com You may be asked to You present may this be asked card when to present you receive this card care. when The you card receive does not care. guarantee The card does not guarantee coverage. You must comply coverage. with You all must terms comply and conditions with all terms of the and plan. conditions Willful misuse of the of plan. this Willful card ismisuse of this card is considered fraud. considered fraud. This plan does not require This plan pre-certification does not require of coverage pre-certification for inpatient of coverage or outpatient for inpatient services. or Claims outpatient will services. Claims will be paid according to be terms You paid may and according be conditions asked to to terms of present the and plan. this conditions In card the when case of of the you an plan. receive emergency, In the care. case seek The of card care an emergency, does not guarantee seek care coverage. You must comply with all terms and conditions of the plan. Willful misuse of this card is You immediately, may be asked then to call present immediately, your family this card physician then when call your you for further receive family assistance physician care. The for card and further direction does not assistance regarding guarantee and follow direction up care. regarding follow up care. considered fraud. coverage. You must comply with all terms and conditions of the plan. Willful misuse of this card is considered Send Claims fraud. to: TPV Send / This Alliance Claims plan does Mailing to: not TPV Address require / Alliance pre-certification 13Mailing Address of coverage for inpatient or outpatient services. Claims will This All others plan does to: CIGNA not require HealthCare, All be others paid pre-certification according to: P.O. CIGNA Box to 188004, HealthCare, of terms coverage and Chattanooga, P.O. conditions for Box inpatient 188004, TN of 37422 the or outpatient Chattanooga, plan. In the Payor services. case TN 62308 of 37422 Claims an emergency, willPayor seek 62308 care be paid according to terms immediately, and conditions then call of your the plan. family In physician the case of for an further emergency, assistance seek and care direction regarding follow up care. immediately, Customer then Service: call Customer your family physician 1.800.XXX.XXXX Service: for further assistance 1.800.XXX.XXXX 14and direction regarding follow up care. Send Claims to: TPV / Alliance Mailing Address CIGNA 24-hour CIGNA Nurseline: 24-hour 1.866.XXX.XXXX Nurseline: 1.866.XXX.XXXX Send Claims to: TPV / Alliance others Mailing to: CIGNA Address HealthCare, P.O. Box 188004, Chattanooga, TN 37422 Payor 62308 All others to: CIGNA HealthCare, P.O. Box 188004, Chattanooga, TN 37422 Payor 62308 Customer Service: 1.800.XXX.XXXX Customer Service: CIGNA 1.800.XXX.XXXX 24-hour Nurseline: 1.866.XXX.XXXX CIGNA 24-hour Nurseline: 1.866.XXX.XXXX Provider: Participant Provider: is enrolled Participant in a limited-benefit is enrolled plan. in a limited-benefit For hospital services, plan. For collect hospital patient services, collect patient responsibility when responsibility service is rendered when service or make is financial rendered arrangements or make financial with the arrangements patient in with the patient in accordance with your accordance policies. with your policies. Provider: Participant is enrolled in a limited-benefit plan. For hospital services, collect patient Provider: Participant responsibility is enrolled in when a limited-benefit service is rendered plan. For or hospital make financial services, arrangements collect patient with the patient in responsibility when service accordance is rendered with your or make policies. financial arrangements 15 AWAY with the FROM patient HOME in CARE AWAY FROM HOME CARE accordance with your policies. AWAY FROM HOME CARE AWAY FROM HOME CARE 012412 012412 2012 Starbridge 2012 Starbridge - Beech Street - Beech Street PPO Plans A V I A N T N E T W O R K A V I A N T N E T W O R K Primary Network: Beech Street Primary Network: Beech Street Connecticut General Life Insurance Company Connecticut General Life Insurance Company Starbridge ® Beech Street Doctor Visit $25 Coverage Effective Date: 00/00/0000Doctor Visit $25 Coverage Effective Date: 00/00/0000 Specialist Specialist $25 $25 ID: Use Primary Insured’s Social Security Number ID: Use Primary Insured’s Social Security Number Network Coinsurance: Network Coinsurance: In 80%/20% Name: Name In 80%/20% Name: Name Out Out 80%/20% 80%/20% Group Name: Group Number: Group Name: Group Number: 11 • No PCP selection required • No referrals required • In-network and out-of-network coverage www.starbridge.com www.starbridge.com SM 3 SM For Benefits, Claim Status, For Benefits, Eligibility Claim or Customer Status, Eligibility Service, or Call Customer Service, 1-8XX-XXX-XXXX Call 1-8XX-XXX-XXXX 7 5 4 You may be asked to present this card when you receive care. The card does not guarantee You may be asked to present coverage. this You card must when comply you receive with all care. terms The and card conditions does not guarantee of the plan. Willful misuse of this card is coverage. You must comply considered with all fraud. terms and conditions of the plan. Willful misuse of this card is considered fraud. This plan does not require pre-certification of coverage for inpatient or outpatient services. Claims will This plan does not require pre-certification of coverage for inpatient or outpatient services. Claims will be paid according to terms and conditions of the plan. In the case of an emergency, seek care be paid according to terms and conditions of the plan. In the case of an emergency, seek care immediately, then call your family physician for further assistance and direction regarding follow up care. immediately, then call your family physician for further assistance and direction regarding follow up care. 13 Send Claims to: Send Claims to: Connecticut General Life Insurance Company, PO Box 55270, Phoenix, AZ 85078-5270 Payor 59225 Connecticut General Life Insurance Company, PO Box 55270, Phoenix, AZ 85078-5270 Payor 59225 Customer Service: Customer 1.800.XXX.XXXX Service: 1.800.XXX.XXXX CIGNA 24-hour CIGNA Nurseline: 24-hour 1.866.XXX.XXXX Nurseline: 1.866.XXX.XXXX 14 Provider: Participant Provider: is enrolled Participant in a limited-benefit is enrolled plan. in a For limited-benefit hospital services, plan. For collect hospital patient services, collect patient responsibility when service responsibility is rendered when or service make financial is rendered arrangements or make financial with the arrangements patient in with the patient in accordance with your accordance policies. with your policies. AWAY FROM HOME CARE AWAY FROM HOME CARE 2012 FundamentalCare 2012 FundamentalCare - CIGNA - HealthCare CIGNA HealthCare PPO PPO 2012 Starbridge 2012 Starbridge - CIGNA - HealthCare CIGNA HealthCare PPO PPO 012412 TPV / Alliance TPV / Alliance TPV Logo / Alliance TPV / Logo Alliance 11 www.fundamentalcare.com www.fundamentalcare.com Logo Logo Primary Network: CIGNA Primary HealthCare Network: PPOCIGNA HealthCare PPO www.starbridge.com www.starbridge.com Secondary Primary Network: CIGNA Beech Primary HealthCare Secondary Street Network: PPOCIGNA HealthCare PPO Network: Beech Street 5 Connecticut Secondary Network: General Life Beech Secondary Connecticut Insurance StreetNetwork: General Company Beech Street Life Insurance Company Connecticut General Life Connecticut Insurance General Company Life Insurance Company Doctor Visit Coverage Effective Date: Doctor $25 Visit $25 Coverage 00/00/0000 Effective Date: 00/00/0000 Doctor Coverage Effective Date: 00/00/0000 Specialist Visit Doctor $25 Coverage Effective Date: 00/00/0000 Visit Specialist $25 $25 $25 ID: AMI Specialist 7 ID: AMI Network Coinsurance: Specialist $25 4 $25 ID: AMI Network Coinsurance: ID: AMI Network In Coinsurance: Network Name: Name In 80%/20% Coinsurance: 80%/20% Name: Name Name: Name In Name: Name Out In 80%/20% SM Out 80%/20% 80%/20% Out 80%/20% Out Account Number: Account 2466518 SM 80%/20% 3 SM 80%/20% Account Number: Number: 2466518 Account 2466518 Number: 2466518 Starbridge ® Cigna PPO Group Name: Group Group Number: Name: Group Number: 012412 Group Name: Group Name: Group Number: Group Number: A V I A N T N E T W O R K A V I A N T N E T W O R K A V I A N T N E T W O R K A V I A N T N E T W O R K • No PCP selection required • No referrals required • In-network and out-of-network coverage You may be asked to present You may this be card asked when to present you receive this card care. when The card you does receive not care. guarantee The card does not guarantee coverage. You may be You asked must to comply present You coverage. may with this be You all card asked terms must when to and comply present you conditions receive with this all card care. of terms the when The plan. and card you conditions Willful receive does misuse not care. of guarantee the of The this plan. card card Willful does is not misuse guarantee of this card is considered coverage. You fraud. must comply coverage. considered with You all fraud. terms must comply and conditions with all of terms the and plan. conditions Willful misuse of the of plan. this card Willful is misuse of this card is This considered plan does fraud. not require considered This pre-certification plan does fraud. not require of coverage pre-certification for inpatient of coverage or outpatient for inpatient services. or Claims outpatient will services. Claims will be This paid plan according does not to require terms This be paid plan pre-certification and according conditions does not to require of of terms the coverage pre-certification plan. and conditions In for the inpatient case of of coverage the an or emergency, outpatient plan. In for the inpatient services. seek case of care or Claims an outpatient will emergency, services. seek care Claims will immediately, be paid according then call to terms be your immediately, paid family and according conditions physician then to of call terms for the your further and plan. family conditions assistance In the case physician of and of for the an direction further plan. emergency, In assistance regarding the case seek and of care follow an direction emergency, up care. regarding seek care follow up care. immediately, then call immediately, your family physician then call for your further family assistance physician and for further direction assistance regarding and follow direction up care. regarding follow up care. Send Claims to: TPV / Send Alliance Claims Mailing to: Address TPV Alliance Mailing Address Send Claims to: TPV / All others to: CIGNA HealthCare, Send Alliance Claims Mailing All others P.O. to: to: CIGNA Box TPV Address 188004, / Alliance HealthCare, Chattanooga, 13 Mailing Address P.O. Box 188004, TN 37422 Chattanooga, Payor 62308 TN 37422 Payor 62308 All others to: CIGNA HealthCare, All others to: P.O. CIGNA Box 188004, HealthCare, Chattanooga, P.O. Box 188004, TN 37422 Chattanooga, Payor TN 62308 37422 Payor 62308 Customer Service: Customer 1.800.XXX.XXXX Customer Service: Customer 1.800.XXX.XXXX Service: Service: 1.800.XXX.XXXX 1.800.XXX.XXXX 14 CIGNA 24-hour CIGNA Nurseline: 24-hour 1.866.XXX.XXXX CIGNA 24-hour CIGNA Nurseline: 24-hour 1.866.XXX.XXXX Nurseline: Nurseline: 1.866.XXX.XXXX 1.866.XXX.XXXX 2012 Starbridge 2012 Starbridge - Beech - Street Beech Street Provider: Participant is enrolled in a limited-benefit plan. For hospital services, collect patient Provider: Participant is enrolled in limited-benefit plan. For hospital services, collect patient responsibility Provider: Participant when service Provider: is enrolled is rendered Participant in a limited-benefit or make is enrolled financial plan. a arrangements limited-benefit For hospital services, with plan. the For patient collect hospital patient in services, collect patient responsibility when service is rendered or make financial arrangements with the patient in accordance responsibility with when your service responsibility policies. is rendered when or service make is financial rendered arrangements or make financial with the arrangements patient in with the patient in accordance with your accordance with your policies. accordance policies. with your policies. 15 AWAY FROM HOME CARE AWAY FROM HOME CARE AWAY FROM HOME CARE AWAY FROM HOME CARE 65 A V I A N T N E T W O R K A V I A N T N E T W O R K Primary Network: Beech Street Connecticut General Life Primary Insurance Network: Company Beech Street Connecticut General Life Insurance Company www.starbridge.com www.starbridge.com You may be asked to present this card when you receive care. The card does not guarantee coverage. You must comply You may with be all asked terms to and present conditions this card of when the plan. you Willful receive misuse care. The of this card card does is not guarantee considered fraud. coverage. You must comply with all terms and conditions of the plan. Willful misuse of this card is This plan does not require considered pre-certification fraud. of coverage for inpatient or outpatient services. Claims will be paid according to terms This plan and does conditions not require of the pre-certification plan. In the case of of coverage an emergency, for inpatient seek care or outpatient services. Claims will immediately, then call be your paid family according physician to terms for further and conditions assistance of and the direction plan. In the regarding case of follow an emergency, up care. seek care immediately, then call your family physician for further assistance and direction regarding follow up care.
PPO or EPO Plans TPV logo 11 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 5 10 18 6 ID card acct name RxBIN 600428 RxPCN 02150000 NSP DOI logo 9 Network Savings Program • No PCP selection required • No referrals required • PPO: In-network and out-of-network coverage • EPO: In-network coverage only, except emergency care 7 Client logo PPO Dr. visit $10/$25 Specialist $10/$25 Hospital ER $50 4 Urgent care $25 Vision Yes Rx $10/20/30 Network coinsurance: In 90%/10% 3 Out 70%/30% Med/Rx deductible applies Cat# 12 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 AND OUTPATIENT PROCEDURES: 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. 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 13 TPV name, PO Box XXXX, Anytown, USA 12345-6789 All others: PO Box XXXX, Anytown, USA 12345-6789 Customer service: 1.800.XXX.XXXX MH/SA: 1.800.XXX.XXXX 14 15 AWAY FROM HOME CARE Strategic Alliances TPV / Alliance logo 11 5 Legal entity name Coverage effective date: MM/DD/CCYY Group: 1234567 7 Issuer (80840) ID: U23456789 01 1 Name: John Public PCP: John Smith PCP name Ln2 PCP phone: 860.555.1212 ID card acct name 10 NSP RxBIN 600428 RxPCN 02150000 logo DOI Network Savings Program • PCP selection encouraged Client logo Open Access Plus No referral required PCP visit $15 Specialist 4 $30 Hospital ER $50 Urgent care $25 Vision Yes Rx $10/$20/$40/90% Rx indiv deduct $50 Network coinsurance: In 90%/10% 9 3 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 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 48 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: CSN name, PO Box XXXXX, Anytown, USA 12345-6789 All other: PO Box XXXXX, Anytown, USA 12345-6789 Customer service: 1.800.XXX.XXXX MH/SA: 1.800.XXX.XXXX 14 We encourage you to use a PCP as a valuable resource and personal health advocate. 15 AWAY FROM HOME CARE Indemnity Plans 5 5 Legal entity name Coverage effective date: MM/DD/CCYY Group: 1234567 Issuer (80840) 1 1 ID: U23456789 01 Name: John Public 10 ID card acct name RxBIN 600428 RxPCN bk 02150000 NSP DOI logo 9 Network Savings Program • No PCP selection required • No referrals required • Patient files claims 7 Client logo Indemnity Rx $10/20%/40%/100% Rx indiv deduct $50 Indiv deduct $300 Family deduct $500 Hospital deduct $200 ER deduct $50 Coinsurance: Medical 80%/20% Med/Rx deductible applies Cat# 3 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. Note: You can reduce your out-of-pocket expenses if you use a Network Savings Program provider. Use of a Network Savings Program provider does not affect your benefit coverage. For help finding a participating provider, please visit our website, or call the toll-free number listed on this card. 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: PO Box XXXX, Anytown, USA 12345-6789 Customer Service: 1.800.XXX.XXXX MH/SA: 1.800.XXX.XXXX 14 67
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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