AURA Policy #02016A Benefits at a Glance Effective Date January 1, 2014
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- Clara Barker
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1 AURA is offering Medical, Dental, Vision, Pharmacy, Medical Evacuation and Repatriation and EAP 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 Deductible Individual Family Out of Pocket Maximum- Excludes Deductible Individual Family Coinsurance (Cigna Pays) Inpatient Hospital Services Facility Physician Outpatient Facility Services Maternity Care Services Infertility (Procedures directly related to diagnosis are covered. Treatment, prescription drugs, and/or other method to bypass, i.e. In-vitro, are not covered) Family Planning (Includes contraceptive devices and surgical sterilization. Reversals are not covered) Lab & Radiology Facility Short Term Rehabilitation (Includes Cardiac Rehab, Physical Therapy, Speech Therapy, Occupational Therapy, Pulmonary Rehab and Cognitive Therapy) 60 days combined maximum per calendar year Physician Visit Prescription Drug purchased outside the United States (Including Oral Contraceptives) Mental Illness and Substance Abuse Inpatient Outpatient Skilled Nursing Facility (120 day maximum per calendar year) Home Health Care (120 day maximum per calendar year) Chiropractic Services (20 day maximum per calendar year) Hospice Unlimited $100 $200 $500 $1,000 90% of covered expenses after 1
2 International Medical Plan TMJ ($1000 maximum per lifetime) 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) 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) 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) Well Child Care (up to age 18) Immunizations (For children birth to age 18) Includes diphtheria, hepatitis A, hepatitis B, measles, mumps, pertussis, polio, rubella, tetanus, varicella, Haemophilus influenza B) Adult Preventive Care Delaware Mandated Autism Spectrum Diss Coverage (Coverage for the screening, diagnosis and treatment of autism spectrum dis and medications as prescribed by licensed providers) Diabetes Equipment & Supplies (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 Durable Medical Equipment Dental Accident (Limited to a continuous course of treatment started within six months of accidental injury to sound natural teeth) Routine Eye Exam and Hardware (One exam, lenses and frames maximum of $250 every Calendar Year) Hearing Exam (One exam every 24 months) Hearing Aids (For dependent children up to age 24, maximum benefit of $1,000 for each unit necessary per ear every three years.) 2
3 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 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. Notice of Grandfathered Plan Status This plan is being treated as a grandfathered health plan under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your coverage may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the plan administrator at the phone number or address provided in your plan documents, to your employer or plan sponsor, or an explanation can be found on Cigna's website at If your plan is subject to ERISA, you may also contact the Employee Benefits Security Administration, U.S. Department of Labor at or This website has a table summarizing which protections do and do not apply to grandfathered health plans. If your plan is a nonfederal government plan or a church plan, you may also contact the U.S. Department of Health and Human Services at 3
4 Global Wellness Programs Pre-Assignment Assistance Program Health and Well-Being Assessment (HA) 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. International Employee Assistance Program (IEAP) Level 2 International EAP Assist Direct dial 24/7 immediate access to confidential services for behavioral issues. Services include telephonic triage for emergent and urgent referrals, crises intervention and referrals to community resources. Referrals for 5 Face-to-Face sessions with licensed behavioral professionals (currently available in 160 countries). Pharmacy Management Purchased Inside the United States Only Prescription Drugs Pharmacy Participating Pharmacy Non-Participating Pharmacy Generic Brand & Non-Brand Mail Order Drugs Generic Mail Order Drugs per 30 day prescription or refill per 30 day prescription or refill per 90 day prescription or refill per 90 day prescription or refill 10% coinsurance per 30 day prescription or refill 10% coinsurance per 30 day prescription or refill In-network coverage only In-network coverage only 4
5 Emergency Medical Evacuation/Repatriation AURA 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. International Dental Plan Calendar Year Maximum (for Class I, II, III) Lifetime Maximum (for Class IV) Deductible (waived for Class I) $2,000 $1,500 $25 Individual / $50 Family Aggregate Class I Class II Class III Preventive Services Diagnostic General Preventive Basic Services Restorative (Basic) Endodontics Periodontics Prosthodontics Removable (Maintenance) Prosthodontics Fixed Bridge (Maintenance) Oral Surgery Major Services Restorative (Major) Prosthodontics Removable (Installation) Prosthodontics Fixed Bridge (Installation) 100%, not subject to 80% after 50% after Class IV Orthodontia (for dependent children under age 19) $1,500 lifetime maximum 50% after 5
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