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INTERNATIONAL

 

International Health, Rx, Dental and Med-Evac Plan and Rates
Plan Basics:
An eligible employee and his or her dependents may enroll in the PPO plan through CIGNA International.  This plan includes coverage anywhere in the world, 24/7.  Enrolled dependents that remain in the United States may utilize health or dental providers from the CIGNA nationwide network, or they may receive care from a non-network provider.  Anyone stationed outside of the U.S. is also covered under the Med-evac benefits included in the plan.
 There are three main ways to receive benefits through the plan.  You may use a network provider or a non-network provider while in the United States.  If you are outside the United States, you may be eligible for benefits when treatment for you or a dependent, is dispensed by a provider that is licensed by the country where treatment is takes place.
 
Summary of CIGNA International Benefits
 
 
 
 
 
 
Plan Features
 
Care provided
OUTSIDE THE U.S.A.
 
Care provided
WITHIN THE U.S.A.
 
 
 
 
 
Care provided by
Preferred Provider
Care provided by
Non-Preferred Provider
 
 
Deductible Limits - Paid by Member
(per calendar year)
 
 
 
 
 
 
Individual
 
$0
 
$0
$0
 
 
Family
 
$0
 
$0
$0
 
 
 
 
 
 
 
 
 
 
Out of Pocket Limits - Paid by Member (per calendar year)*
 
 
 
 
 
 
 
Individual
 
$500
 
$500
$1,500
 
 
 
Family
 
$1,500
 
$1,500
$4,500
 
 
*Does not include outpatient prescription drug expenses
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Lifetime Maximum
 
Unlimited
 
Unlimited
Unlimited
 
 
 
 
 
 
 
 
 
 
Physician Services
 
 
 
 
 
 
 
Non-surgical office visits  
 
90%
 
90%
70%
 
 
Other Charges
 
90%
 
90%
70%
 
 
 
 
 
 
 
 
 
 
Hospital Services
 
 
 
 
 
 
 
Inpatient
 
90%
 
90% after a $250 Co-pay
70% after a $250 co-pay
 
 
Outpatient
 
90%
 
90%
70%
 
 
 
 
 
 
 
 
 
 
Other Medical Expenses
 
90%
 
80%
80%
 
 
 
 
 
 
 
 
 
 
Alcohol, Drug Abuse, Mental Disorders
 
 
 
 
 
 
 
Inpatient
 
90%
 
90% after a $250 Co-pay
70% after a $250 Co-pay
 
 
Outpatient
 
90%
 
90%
90%
 
 
 
 
 
 
 
 
 
 
Skilled Nursing Facility
 
 
 
 
 
 
 
Inpatient - 120 days calendar year max
 
90%
 
90% after a $250 Co-pay
70% after a $250 Co-pay
 
 
 
 
 
 
 
 
 
 
Hospice Care
 
 
 
 
 
 
 
Inpatient
 
90%
 
90% after a $250 Co-pay
70% after a $250 Co-pay
 
 
Outpatient
 
90%
 
90%
70%
 
 
 
 
 
 
 
 
 
 
Home Health Care
 
 
 
 
 
 
 
Outpatient - 120 visits calendar year max
 
90%
 
90%
70%
 
 
 
 
 
 
 
 
 
 
Wellness
 
 
 
 
 
 
 
Routine Physical Exams
(includes immunizations);
see schedule of details below
 
90%
 
100%
70%
 
 
Schedule of details - Routine Physical Exams:
•Children up to age 18: 6 exams in first 12 months of life; 2 exams in 13th - 24th months of life; 1 exam every 12 months thereafter
 
 
 
 
 
 
 
•Children age 18+ and adults up – 1 exam every 12 months
 
 
Routine Gynecological Exams &
Pap Smears
 
1 annual exam and pap smear
 
 
 
 
 
 
 
 
 
 
 
 
Routine Mammograms
(females age 40+)
 
1 screening per calendar year
 
 
 
 
 
 
 
 
 
 
 
 
Routine Digital Rectal Exam (DRE) & Prostate Specific Antigen (PSA) Test (males age 40+)
 
1 test per calendar year
 
 
 
 
 
 
 
 
 
 
 
 
Routine Hearing Exam
 
1 exam every 24 months
 
 
 
 
 
 
 
 
 
 
 
 
Routine Eye Exam
 
100% benefit with 1 exam every 24 months
 
 
 
 
 
 Eyewear
 
100% for eyewear, not subject to deductible, up to $250 every 24 months
 
 
 
 
Prescription Drugs (includes contraceptives)
 
80%
 
100% after copay*
80%
 
 
*Using the U.S. CIGNA Pharmacy Management Network - $10 generic / $20 brand name
 
 
 
 
 
 
 
 
 
 
 
 
Maternity Expenses
 
90%
 
90%
70%
 
 
Covered as any other medical expense and is provided for an employee and spouse and all female family members.  In addition, coverage is provided for diagnosis only of underlying cause(s) of infertility.
 
 
 
 
 
 
 
 
 
 
 
 
Emergency Assistance Services
 
100% with no deductible
 
Not Applicable
Not Applicable
 
 
 
Medical Emergency Services
 
Covers Services for evacuation, provider referrals, return transportation after evacuation, return of dependent children, emergency medication.
 
 
Non-Medical Emergency Services
 
Legal referral assistance, translation services, travel assistance, emergency message transmittal, assistance with travel documents (lost or stolen passports; obtaining visas).
 
 
 Click here for a Complete Version of the Policy
Monthly Premiums:
International Plan Rate Chart (Monthly)
PPO/Dental/Medevac
Single $539.72
$269.86
Husband & Wife $1,378.37
$689.19
Employee & Child(ren) $1,155.16
$577.58
Family $2,117.27
$1,058.64
Italicized figure represents amount deducted per paycheck.
Monthly COBRA Premiums:
International Plan COBRA Rate Chart (Monthly)
PPO/Dental
Single $721.60
Husband & Wife $1,853.25
Employee & Child(ren) $1,550.83
Family $2,851.46