Resourcing Christian Education International Policy # 06100A Benefits at a Glance Effective Date August 1, 2013
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- Mercy Farmer
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1 Resourcing Christian Education International is offering Medical, Vision, Pharmacy, and Medical Evacuation and Repatriation benefits through Cigna Global Health Benefits to our employees. This comprehensive international healthcare program allows our employees and their families to access quality healthcare anywhere in the world. The following pages will provide a general overview of the plan designs for our employees on international assignment. International Medical Plan Lifetime Maximum Benefit $5,000,000 Deductible Individual Family Out of Pocket Maximum - Includes Deductible Individual Family Deductible/Out of Pocket Accumulation $500 $1,000 $1,250 $2,500 $2,500 $5,000 $1,000 $2,000 Cross applies between International, In network and Out of network U.S. Coinsurance (Cigna Pays) 100% after 100% after 80% after Inpatient Hospital Services Facility Physician 100% after deducible 100% after 100% after 100% after 80% after 80% after Outpatient Facility Services 100% after 100% after 80% after Infertility (Procedures directly related to diagnosis are covered. Treatment, prescription drugs, and/or other method to bypass, i.e. In-vitro, are not covered) Not Covered Not Covered Not Covered Family Planning Women s Services -Inpatient hospital facility -Outpatient hospital facility -Surgical services such as tubal ligation are covered (excluding reversals) -Includes contraceptive devices as ordered or prescribed by a physician Family Planning Men s Services -Inpatient hospital facility -Outpatient hospital facility -Surgical services such as vasectomy are covered (excluding reversals) 100% after 100% after 100% after 80% after 100% after 80% after 1
2 International Medical Plan Maternity Care Services 100% after 100% after 80% after Abortion Standard included nonelective 100% after 100% after 80% after procedures only Lab & Radiology Facility 100% after 100% after 80% after Short Term Rehabilitation 100% after 100% after 80% after Includes Cardiac Rehab, Physical Therapy, Speech Therapy, Occupational Therapy, Pulmonary Rehab and Cognitive Therapy Calendar Year Maximum: 60 days for all therapies combined Physician Visit 100% after 100% after 100% after Prescription See Pharmacy Management Section 80% after Mental Illness and Substance Abuse Inpatient Outpatient 100% after 100% after 100% after 100% after 80% after 80% after Inpatient Services at Other Health 100% after 100% after 80% after Care Facilities: Includes Skilled Nursing, Rehabilitation and Sub-Acute Calendar Year Maximum: 120 days combined Home Health Care 100% after 100% after 80% after Calendar Year Max: 90 days Chiropractic Services 100% after 100% after 80% after (20 day maximum per plan year) Hospice Inpatient and Outpatient 100% after 100% after 80% after TMJ 100% after 100% after 80% after ($1,000 maximum per lifetime) Diabetes Equipment & Supplies 100% after 100% after 80% after (Prescribed and recommended in writing by a physician. Equipment included are: insulin pumps, blood glucose meters and strips, urine testing strips, insulin, syringes, lancets, alcohol swabs and pharmacological agents for controlling blood sugar) External Prosthetic Appliances 100% after 100% after 80% after Durable Medical Equipment 100% after 100% after 80% after Dental Accident (Limited to a continuous course of treatment started within six months of accidental injury to sound natural teeth) 100% after 100% after 80% after 2
3 International Medical Plan Well Child Care Immunizations (All ages) Includes diphtheria, hepatitis A, hepatitis B, measles, mumps, pertussis, polio, rubella, tetanus, varicella, Haemophilus influenza B) Adult Preventive Care Travel Immunizations (Employee and Dependent immunizations required for travel are included.) Papanicolaou Screening Test (One test per calendar year for females over age 18) Prostate Cancer Screening (One test per calendar year for males over age 50) Mammograms (One baseline exam for asymptomatic women ages 35-39; one exam every two years for asymptomatic women ages 40-49; one exam annually for women age 50 and over and whenever prescribed) Lead Poisoning Screening (For children at or around 12 months and children under age 6 who are considered to be high risk) Colorectal Cancer Screening (Age 50 and older or any person deemed as high risk of colon cancer) Resourcing Christian Education International 80% after 80% after Allergy Testing / Treatment 100% after 100% after 80% after 3
4 International Medical Plan Alternative Therapies and Nontraditional Medical Services (Outside the United States) Herbalist, Massage Therapist, Naturopath Calendar Year Maximum: $1,000 Resourcing Christian Education International 100% after Not Covered Not Covered Acupuncture 100% after 100% after 80% after Bereavement Counseling 100% after 100% after 80% after Inpatient and Outpatient Services Wigs (for hair loss due to alopecia 100% after 100% after 80% after areata) Calendar Year Max: $500 Nutritional Evaluation 100% after 100% after 80% after Calendar Year Max: 3 visits per person however, the 3 visits will not apply to treatment of diabetes Nutritional Formulas 100% after 100% after 80% after Obesity/Bariatric Surgery Not covered Not Covered Not Covered Emergency and Urgent Care Services Includes: Physician s office visit, Emergency Room, Outpatient professional services, Urgent care facility, X-ray and/or lab, Advanced radiological imaging and Ambulance 100% after 100% after 100% after (except if not a true emergency, then 80% of covered expenses after plan ) 4
5 International Medical Plan Routine Eye Exam Exam: (No Maximum) One every 24 months Hardware: One pair every 24 months Maximum Benefit: $150 Hearing Exam: One every 24 months Hardware: Limited to dependent children under age 24, maximum of $1,000 per hearing aid unit necessary for each ear, every three years. 100% after 100% after 100% after 100% after 80% not subject to 80% after 80% after Direct Access to Obstetricians and Gynecologists You do not need prior authorization from the plan or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, visit or contact customer service at the phone number listed on the back of your ID card. Selection of a Primary Care Provider This plan generally allows the designation of a primary care provider. You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members. For children, you may designate a pediatrician as the primary care provider. 5
6 Global Wellness Programs Pre-Assignment Assistance Program Health and Well-Being Assessment (HA) Certification Requirements U.S. Outof-Network Cigna Pharmacy Management Cigna's Pre-Assignment Assistance is a unique clinical program that offers comprehensive case management, care coordination, inpatient management, evacuation assistance, and online expert second opinions for employees and dependents either in the U.S. or abroad. The tool can be accessed prior to or during assignment through Cigna's secure web portal Cigna Envoy. Employees that utilize the Pre-Assignment Assistance Program are more likely to have a successful assignment. The HA is a short, online assessment that is core to our wellness solutions and the first step to identifying personal health risks. Those who complete the HA, immediately receive a personalized health risk profile report. The HA is medically validated by the World Health Organization. Will apply with penalties for non-compliance for U.S. confinements. Penalties: $300 penalty applied to hospital in-patient charges for failure to pre-certify admission. Benefits are reduced 50% for any admission not certified or additional days not deemed medically necessary. A service provided through Cigna Pharmacy Management, a Cigna company, which offers a managed pharmacy benefit plan for prescription drugs purchased in the United States at participating retail pharmacies. Mail order drugs will also be available via TelDrug, but can be shipped oversea to APO addresses only. Some limitations may apply. Pharmacy Management Purchased Inside the United States Only Prescription Drugs Pharmacy Participating Pharmacy Non-Participating Pharmacy Generic 80% after Brand & Non-Brand 80% after Mail Order Drugs Generic In-network coverage only Mail Order Drugs In-network coverage only 6
7 Emergency Medical Evacuation/Repatriation Emergency Evacuation Family Travel Arrangements Return of Dependent Children Repatriation of Mortal Remains Return of Traveling Companion 100% coverage not subject to the for services approved by International SOS Economy round-trip airfare to the place of hospitalization for one family member for hospitalizations in excess of 7 days One-way Economy airfare to return dependent children to their country of residence 100% coverage not subject to the In the event of hospitalization or evacuation, and a traveling companion s air ticket is no longer usable, one-way economy airfare will be provided to the original point of departure. 7
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