HomeMy WebLinkAboutExhibit15CIGNA
Health insurance options for you.
Help with minor medical expenses.
Starting Out
Hurry! Open Enrollment Ends <date>,
or you have 31 days from your hire date.
Who is eligible?
Text
When will my coverage begin?
Text
Starbridge Choices is not a major medical plan.
Rates starting at only
$0 00 weekly
•
Starbridge C oices
A CIGNA Health Insurance Plan
a limited -benefit medical plan
1-800-000-0000
www.starbridgechoices.com
SBS547.1 _0000
050207
STEP 1: Choose a Limited -Benefit Medical Plan.
Which plan is right for you? Whether you are single or married, young or middle-aged, with or without children,
Starbridge Choices has the,right coverage for you. In order to take advantage of the best coverage available, you should enrr
Level 3. If it's too expensive, there are other plans to choose from below.
Level 3
You understand that unexpected medical bills can be expensive and you want the best coverage available.
This plan includes additional benefits and higher omits fto meet you and your loved one's needs.
• $10 Doctor Visits
• $2,000 Outpatient Care
• - $5,000 Inpatient Care
• $600 Prescription Benefit
• Prescription Discounts'
• $2,500 Surgery Benefit/ $2,500 Maternity Benefit
• $10 Doctor Visits
• $1,500 Outpatient Care
• $3,000 Inpatient Care
$300 Prescription Benefit
• Prescription Discounts' j5
• $1,500 Surgery Benefit/ $1,500 Maternity Bene
•
• $10,000 Accident Coverage
• $25,000 Accidental Death Benefit
• CIGNA 24-Hour Employee Assistance Programs""
• Term Life Insurance
Online Tools
CIGNA Bridges"" Network
$5,000 Accident Coverage
$15,000 Accidental Death Benefit
CIGNA 24-Hour Employee Assistance P
Term Life insurance
Online Tools
CIGNA Bridge Network
Level 1
v.,
You feel you are healthy and only see a doctor once in awhile 'However,.
basic coverage arid allows you to --get medical attention if needed
• $15 Doctor.Visits
$1,000 Outpatient Care
$2,000 Inpatient Care
• Prescription Discountsf
• $2,000 Accident Coverage:
The benefits above are provided by policy form SBCII-GMP-02. Starbridge Choices is not a major medical plan.
STEP 2: Choose the Supplemental Plan.
DentalNision* Plan
The key to a healthy smile is to take care of
your teeth before problems begin.
• Reimburses for 45 dental procedures/$25 annual deductible
• Save on eye exams, frames, lenses & contacts
Weekly Rates* - Myself only $0.00
Myself and 1 dependent $0.00
Family $0.00
the disco -sit vision program is not irsuanoe. The rates above include the cost of the
asco nt vision program. ($0.00 eaves only, $0.00 employee + 1, $0.00 family)
'The prescription discount program is not insurance.
Questions, call a Benefits Specialist: 1-800-000-0000
• www.starbridgechoices.com
Once you've enrolled, you'll also receive access to Healthy
Rewards, a discount health and wellness program.
You can save up to 60% on fitness center memberships, weight
—anagement programs, health -related magazines, and much more!
Level 3 - Weekly Rates
Myself only $0.00
Myself and 1 dependent $0 00
Family $0.00
Level 2 - Weekly Rates
Myself only .'
Myself and 1 dependent
Family.
CIGNA
STEP 3: Enroll Now.
Group Number: 0000
Enrollment Form
Connecticut General Life insurance Company
P.O. Box 55270 • Phoenix, AZ • 85078-5270
Please give your enrollment form to your
Human Resources Manager.
First Name Initial
Last Name
Soc. Sec # Hire Date Unit #
Address
City State Zip
Which Plan or Plans?
t want the Level 3 Plan
_ I want the Level 2 Plan
_ I want the Level 1 Plan
I want the Dental Plan
Who Do You Want to Cover?
Check ony one, even if multiple plans are chosen.
I want to cover myself only
_ I want to cover myself and 1 dependent
_ I want to cover my family
Dependents •
If additional spaces are needed, please attach separate sheet.
Spouse's Full Name Soc. Sec. # (Date of Birth
Child's Full Name Son/Daughter Soc. Sec. # Date of Birth
Beneficiary
Person who will reeve benefits in the event of your death.
Print Full Name Relationship to You
For Oregon residents only.
Have you had prior coverage (less than a 63 day gap)? Please forward us
the Certificate of Creditable Coverage from your priorcarrier.
For Florida residents only.
My person who knowingly and with intent to injure, defraud, or deceive any
insurer files a statement of claim or an application contaning any false,
incomplete, or misleading information is guilty of a felony of the third degree.
For aA other states' residents.
Any person who knowingly presents a false or fraudulent claim for
payment of a loss or benefit or knowingly presents false information in an•
application for insurance is guilty of a crime, maybe violating state law,
and may be subject to fines and confinement in pnson.
X
tmployee Signature Date
SBCII-ENRL-02.
Sign Here To Enroll Date
Authorization: I hereby elect to participate in the Startxidge Choices Insurance Plan for
benefits made available under Internal Revenue Code Section 79 105,106,125 and these
Sections as amended. I understand that the Plan will automaticacanrert to pre-tax status
any.eligllbe payroll deductions which are provided through the . I understand that b
participating in this Plan my Social Secunty benefits may be reduced since these will
be deducted before my salary is taxed. this election will remain in effect for the Plan Year. My
election CANNOT be changed during the Plan Yearn accordance with Internal Revenue
ServiceGuidettnes unless a qualifying event occurs which includes: marriage, divorce, legal
separation, death of spouse, birth Or bigal adoption of chid, death of chid spousal change of
employment affecting insurance coverage, etgibthty to Medicare or Medicaid or change in
residence affecting insurance coverage. Any person who end with intent to injure,
defraud or deceive any insurer, files a statement of claim oran containing any false
incomplete, or misleading information isguilty of a crime and may be subject to fines and
confinement in prison.
Declination Notice: No, I do not wish to enroll in the coverage offered above.WAIVER OF
COVERAGE: Failure to elect coverage (for yourself and/or any of your dependents) during the
Open Enrollment Period may result in no coverage until the next Open Enrollment Period. It
may not be necessary to wait for the next Open Enrotnent Period if you qualify as a Special
Enrollee. Please fill out top, sign, and date.
Signature if Declining Coverage Date
What you get with the Starbridge Choices limited -benefit medical plan.
Starbridge Choices is a basic health plan to help cover the bills for minor illnesses and off -the -job accidents such as the flu or a broken
arm. After you enroll, we'll provide you with tools to help save you money and get the most out of your benefits.
eve 3
.Level 2
Level 1
$15
100%
0maximum
0
(
Doctor Office Visits*
copay
plan pays
$10
100%
$10
100%
Outpatient Care
deductible
plan pays/you pay
maximum amount paid by plan
$150/year
80%/20%
$2,000/year
$100/year
80%/20%
$1 ,500/year
$50/year
80%/20%
$1,000/year
Inpatient Care
deductible
plan pays
amount paid by plan
$0
100%
$5,000/year
$0
100%
$3,000/year
$0
100%
$2,000/year
In -Hospital Surgery
deductible
plan pays
Maximum amount paid by plan
$0
100%
$2,500/occurrence
$0
100%
$1,500/occurrence
not included
Maternity Benefit
deductible
plan pays
maximum amount paid by plan
$0
100%
$2,500/occurrence
$0
100%
$1,500%ccurrence
not included
Non ER Care in ER Room*
• deductible
plan pays/you pay
maximum amount paid by plan
$100/occurrence
50%/50%
$500/year
$100/occurrence
50%/50%
$500/year
$100 / occurrence
50%/50%
$500/year
0
ccopay
m
5
Wellness Benefit'
plan pays
number of occurrences
maximum amount paid by plan
$20
100%
1 /year
$100
$20
100%
1 /year
$100
not included
r
as -
El`
Z:•
ES
Prescription Benefit
copay
plan pays
maximum amount paid by plan
discount program included§
$15/generic, $30/Pref. brand
100%
$600/year
discount program included§
$15/generic, $30/Pref. brand
100%
$300/year
discount program
included§
-mot
x
Accident Coverage
deductible
plan pays/you pay
number of occurrences
maximum per occurrence
maximum amount paid by plan
$100/occurrence
80%/20%
2/year
$5,000
$10,000/year
$50/occurrence
80%/20%
2/year
$2,500
$5,000/year
$50/occurrence
80%/20%
2/year
$1,000
$2,000/year
•
Accidental Death Benefit
plan pays
$25,000
$15,000
$10,000
Additional Services
CIGNA 24-Hour EAP'
health information line
audio library of health topics
EAP consultation
unlimited
unlimited
up to 3/year
unlimited
unlimited
up to 3/year
unlimited
unlimited
up to 3/year
Online Tools
locate doctors in our network
compare doctors by price
track status of claims
included
included
included
The benefits above are provided by policy form SBCI1-GMP-02. All yearly benefits are paid per coverage year.
Starbridge Choices utilizes the CIGNA Bridgesm Network that provides discounts on outpatient and inpatient services.
* The total amount Starbridge Choices pays will count toward your Outpatient Care maximum.
§ The prescription discount program is not insurance. ' Provision varies by state.
Questions, call a Benefits Specialist: 1-800-000-0000 • www.starbridgechoices.com
Some people need more than just a medical plan.
DentalNision Plan
The Dental Plan provides coverage for common preventive and basic procedures,
and you can save even more money by visiting a CIGNA Network dentist with more
than 69,000 participating nationwide.*
• $25 annual deductible
• Reimbursement amounts examples:
1. Exam - $17
2. Routine Cleaning - $30
3. Tooth Removal $39
4. Filling (3 surfaces) - $56
The key to a healthy smite is to take care of your teeth and gums before problems begin. Receiving regular dental care often
catches minor problems before they become major and expensive to treat. For every $1 spent on preventive dental care,
$8-$50 could be saved in restorative and emergency treatment (Source: American Dental Hygienist Association). You'll find that
coverage for most preventive services is provided at a reasonable cost.
Example of ,How the Dental Plan Works For illustrative purposes only. Actual fee schedules vary by location.
Periodic Oral Exam (6 month cleaning) Average Cost
$36
CIGNA Network Discount* - -$12 You Save $29
Dental Plan reimburses you —$17
You Pay :; $7
!For a complete list of covered procedures and participating network dentists visit www.starbridgechoices.com
• Vision Discount Program The vision discount program is not insurance
You and your covered family members also receive a membership in the Vision One Netwo�
• ; Save up to 60% on frames and lenses
• Save up to $10 on eye examinations
Underwritten by Connecticut General life Insurance Company. This plan is not available in WA. Plan design and rates may vary. "CIGNA" and 'CIGNA HealthCare' refer to various operating subsidiaries of CIGNA Corporation.
Products and services are provided by These subsidiaries and not by CIGNA Corporation. These subsidiaries include Connecticut General life Insurance Company, Tel -Drug, Inc. and its afhlia(es, CIGNA Behavioral health,
Inc., Intracorp, and HMO or service company subsidiaries of CIGNA Health Corporation and CIGNA Denial Health, Inc.
SPECIAL ENHOLLMtNt
If you are deckning enrollment for yourself or your dependents (including your spouse) because of other health insuraarice or group health plan coverage, you may be able to urrd
yourself and your dependents in thus plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents'
other coverage). However, you must request enrollment within 31 days after your or your dependents' other coverage ends (or after the employer stops contributing toward the other
coverage). in addition, if you have a new dependent as a result of marriage, birth, adoption, placement for adoption, or Quahked Medical Chid Support Order you may be able to
enroll yourself and your dependents. However, you must request enrollment wittun 31 days after the marriage, birth, adoption, or placement fer adoption.
Loss of coverage (non -COBRA) that can qualify for Special Enrollment includes, but is not limited to:
Loss of eligibiily for coverage as a result of legal separation, divorce, cessation of dependent status (such as attaining the maximum age to be ekgble as a dependent chid under
the plan), death of an employee termination of employment, reduction in the number of hours of employment, and any loss of e . laity for coverage when a plan no longer offers
any benefits to the class of sardarly situated individuals that includes the individual.
To request special enrollment or obtain more information, contact a Customer Service representative at 1-800-O00-0000. Representatives are ava0able Monday through Friday, 5
AM to 6 PM, Mountain Standard time.
LIMITATION FOR PRE-EXISTING CONDITION I. - A Pre-existing Condition is
one in which you have teen diagnosed, treated or sought advice from a physician during the 6
months before becoming insured. A condition will no longer be pre-existing after 12 months of
continuous coverage.
Benefits are not paid for a Pre -Existing condition. Pre-existing coverage does not apply to a
pregnancy or to newborn or adopted children. The pre-existing limitation can be reduced by
the amount of time you were previously insured if you became insured under this policy within
63 days after termination of prior coverage.
BENEFIT LIMITATIONS' - Coverage is not provided for services, supplies or
equipment when a charge is not usually made in the absence of insurance.
No coverage is provided for foss caused by or resulting from:
1. Injury or sickness arising out of or in the course of employment;
2. War or act ofwar
3. Expenses which are not ordered by a Physician;
4. Cosmetic surgery. This does not apply to reconstructive surgery due to:
a. trauma, infection, or other disease; or
b. congenital dose or aramahy o a covered dependent newborn or adopted inlaot or
c. surgery on a non -diseased breast to restore and achieve symmetry between two
breasts following a mastectomy.
5. Hearing examinations or hearing aids;
6. Vision services and supplies other than fora disease prod, racial kiratotomy, Iwralomi1wsis or
e* mer laser photo refredit leraectomyorsimilartypepreceduresorservices;
7. Charges made by a health care provider who is a member of your family or who is living
with you;
8. Custodial Care confinement in a Hospital or Skilled Nursing Facility;
9. Horne Health Care Services, unless provided in place of a Hospital confinement.
10. Commission of a felony;
11. Manipulations of the muscutoskeletal system;
12. Treatment of mental or nervous disorders, alcoholism, or any form of substance abuse;
13. Intentionally self-inflicted injury or suicide attempt;
14. Dental care and treatment, except that required by injury and rendered within 6 months
of the injury;
15. Treatment which is experimental or investigational.
16. Any expense incurred after the date the policy terminates.
DEFINITION OF DEPENDENT'S - Your Dependent is:
1. Your spouse,
2. Your unmarried children under 19 years old, and
3. Your unmarried children who are 19 years old through 25 years old if the child is
attending an accredited school full time and is dependent on you for support.
ACCIDENTAL DEATH - No coverage is provided by death caused by:
1. War or act of war
2. Suicide within 2 years of your effective date,
3. Medical or surgical treatment of sickness of disease, or
4. Flight except as a passenger in a commercial airline.
DENTAL EXCLUSIONS
Benefits will not be paid for dental expenses arising from or in connection with:
1. Services or supplies for which a charge is not customarily made in the absence of
insurance.
2. Injury arising out of or in the course of employment; or which is compensable (in South
Dakota, which is paid) under any Workers' Compensation or Occupational Disease Act or
Law.
3. Declared or undeclared war, or act of war.
4. A service furnished to a Covered Person for
a. Cosmetic purposes, unless needed as a result of Injury. facing on crowns, or pantia,
posterior to the second bicuspid shall always be considered cosmetic;
b. Dental care of a congenital or developmental malformation (unless benefits for
orthodontic services are specifically provided in the Schedule of Benefits).
5. Replacement of lost or stolen appliances.
6. Appliances, restorations, or procedures for the purpose of altering vertical dimension,
restoring or maintaining occlusion, splinting, or replacing tooth structure lost as a result of
abrasion or attrition, or treatment of disturbances of the temporomandibutar joint. in
Arkansas, treatment for the temporomandibular joint is not excluded.
7. A service not furnished by a Dentist, except:
a. That performed by a Dental Hygienist under the supervision of a Dentist;
b. X-rays ordered by a Dentist
B. Intentionally sell -inflicted injury or suicide attempt.
TERMINATION
A Covered Person's coverage will terminate at 12:01 a.m. Standard Time at Your home
on the earliest of the following:
1. The date the Policy terminates;
2. The date this Certificate terminates;
3. The date coverage is terminated by Us for all certificate holders in Your state;
4. The date We receive Your written request to have Your insurance terminated.
5. The end of the period for which premium is paid, subject to the Grace Period.
6. The date a Covered Person enters the armed forces of any country. Membership in the
reserves or in the National Guard is not deemed entry into the armed forces. Active duty
service in the reserves or National Guard for a period of 31 consecutive days or more will
be deemed entry into the armed forces.
7. With respect to a Dependent spouse, the date the spouse no longer qualifies as a
Dependent, unless coverage is continued as stated in the Continuation of Coverage
provision.
8. With respect to a Dependent child, the date that child no longer qualifies as a Dependent,
unless coverage is continued as staled in the Continuation of Coverage provision.
At least 60 days prior written notice will be given to You if We terminate Your coverage for any
reason, except for nonpayment premium.
FOOTNOTES
This provision or limitation varies by state.
tinderwri len by Connecticut General Life Insurance Company. This plan is not available in WA Plan design and rates may vary. "CIGNA' and "CIGNA HeatlhCare" refer to various operating subsidiaries of CIGNA Corporation,
Products and services are provided by these subsidiaries and not d CIGNA Corporation. These subsidiaries include Connecticut General Life Insurance Company, Tel -Drug, Inc. and its affiliates, CIGNA Behavioral Health,
Inc., Intracorp, and HMO or service company subsidiaries of CIGNA Health Corporation and CIGNA Dental Heath, Inc.
This brochure is intended as a brief summary of the Slarbridge Choices Plan; the insurance Certificate, the insurance policy and state specific variations, are the official documents governing this Plan. Administered by;
Connecticut General Lite Insurance Company, P.O. Box 55270, Phoenix, AZ 85078-5270. 050207