QUICK GUIDE TO CIGNA ID CARDS
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QUICK GUIDE TO CIGNA ID CARDS 591795 z 04/21
We pack a lot of important information on Table of contents
our ID cards.
Managed care plans��������������������������������������������������������������������������������� 2
This brochure can help define and clarify information that
appears on Cigna’s most common customer ID cards. It Networks:
can also help you understand the requirements associated Network Open Access����������������������������������������������������������������������2
with our various plans, allowing you to quickly and
efficiently serve your patients. Open Access Plus��������������������������������������������������������������������������������2
We may occasionally update this brochure during the year. HMO Open Access or POS Open Access ����������������������������2
Download the most current version at Cigna.com > Health HMO, POS, or HMO POS ��������������������������������������������������������������� 4
Care Providers > Coverage and Claims > ID Cards. Network or Network POS ������������������������������������������������������������� 6
PPO or EPO������������������������������������������������������������������������������������������� 6
Important information about this guide
Cigna SureFit® ������������������������������������������������������������������������������������� 8
Please note: Some Cigna ID cards include a “G” in the
upper-right corner, and may have different service
channels, including customer service phone numbers Individual & Family Plans ������������������������������������������������������������������� 10
and claim appeal addresses. Networks:
Sample standard Cigna ID card images are shown in this Connect����������������������������������������������������������������������������������10
guide. However, the actual content may vary to conform Cigna Plus ������������������������������������������������������������������������������10
to a state’s legislative and regulatory requirements. An
ID card is not a guarantee of coverage, and benefits should Medicare plans��������������������������������������������������������������������������������������������12
be verified.
Medicaid plans������������������������������������������������������������������������������������������� 14
Always be sure to check the back of your patient’s ID card
for the correct contact information. You can also refer to Cigna Global Health Benefits® plans ������������������������������������������� 16
the Important contact information page in the back of this
Networks:
guide, or refer to the Cigna Reference Guide for physicians,
Networks in the U.S.: PPO or OAP������������������������������������16
hospitals, ancillaries, and other health care professionals by
logging in to the Cigna for Health Care Professionals Networks outside the U.S.: Vary by location������������������16
website (CignaforHCP.com) > Resources > Reference
Guides > Medical Reference Guides > Health Care Cigna Choice Fund® plans ������������������������������������������������������������������18
Professional Reference Guides.
Networks:
Vary by plan ��������������������������������������������������������������������������18
Shared Administration Repricing plans ��������������������������������������18
Networks:
Shared Administration Open Access Plus����������������������18
Shared Administration PPO������������������������������������������������18
Shared Administration Local Plus ������������������������������������18
Strategic alliance plans ���������������������������������������������������������������������� 20
Networks:
Vary by plan �������������������������������������������������������������������������������������� 20
Cigna + Oscar���������������������������������������������������������������������������������������������22
Indemnity plans �������������������������������������������������������������������������������������� 24
The myCigna® App �������������������������������������������������������������������������������� 26
Important contact information �������������������������������������������������������28
1
MANAGED CARE PLANS
Network: Network Open Access
18 WWW.CIGNA.COM
CSN logo
TPV logo 11 Client You may be asked to present this card when you receive care. The card does not guarantee coverage.
Tiered Benefits 6 logo You must comply with all terms and conditions of the plan. Willful misuse of this card is considered fraud.
Legal entity name 5 5 12 INPATIENT ADMISSION or 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
Coverage effective date: MM/DD/CCYY Network Open Access for your pre-certif ication requirements. Failure to do so may af fect benef its. In an emergency, seek care immediately, then call your
Group: 1234567
7 No referral required primary care doctor as soon as possible for further assistance and directions on follow-up care within ### hours.
Issuer (80840) PCP Visit $10/$25 For information about mental health services and coverage, call 1-XXX-XXX-XXXX
ID: U23456789 01 1
Specialist $10/$25 Med Group: Sunset Med Group
Name: John Public Hospital ER 4 $50 Send Claims to: 123 Main Street, Suite 999, Anytown, USA 12345-6789 13
PCP: James Smith 8
Urgent Care $25
For Dental call ABC Company 1-XXX-XXX-XXXX (not a Cigna Company)
Vision Yes
PCP Name Ln2 For Vision call ABC Company 1-XXX-XXX-XXXX (not a Cigna Company)
Rx $10/20%/40%/100%
PCP Phone: XXX.XXX.XXXX Rx Indiv Deduct $50 Cigna Vision PO Box 385018, Birmingham, AL 35238-5018
ID card acct name 10 Cigna Claims: PO Box XXXXX, Anytown, USA 12345-6789
NSP Coinsurance applies
3 TPV Name, PO Box XXXXX, Anytown, USA 12345-6789
RxBIN XXXXXX RxPCN XXXXXXXX logo 9 CSN Name, PO Box XXXXX, Anytown, USA 12345-6789
DOI Network Savings Program SAR Customer Service: 1-XXX-XXX-XXXX 14 MH/SA: 1-XXX-XXX-XXXX
PCP required Referral required Away from Home Care Out-of-network benefits
Encouraged No No No
For more information, see the next page.
Network: Open Access Plus
WWW.CIGNA.COM
CSN logo 18 You may be asked to present this card when you receive care. The card does not guarantee coverage.
TPV logo 11 Client
You must comply with all terms and conditions of the plan. Willful misuse of this card is considered fraud.
Tiered Benefits 6 logo
Legal entity name 5
12 INPATIENT ADMISSION or 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
Coverage effective date: MM/DD/CCYY 7 Open Access Plus for your pre-certif ication requirements. Failure to do so may af fect benef its. In an emergency, seek care immediately, then call your
Group: 1234567 No referral required primary care doctor as soon as possible for further assistance and directions on follow-up care within ### hours.
Issuer (80840) PCP visit $10/$25 For information about mental health services and coverage, call 1-XXX-XXX-XXXX
Specialist $10/$25
ID: U23456789 01 1 Hospital ER $50 4
Med Group: Sunset Med Group
Send Claims to: 123 Main Street, Suite 999, Anytown, USA 12345-6789
Name: John Public Urgent care $25
Vision Yes For Dental call ABC Company 1-XXX-XXX-XXXX (not a Cigna Company)
PCP: James Smith 8 For Vision call ABC Company 1-XXX-XXX-XXXX (not a Cigna Company)
PCP Name Ln2 Rx $10/20/30
Network Coinsurance: Cigna Vision PO Box 385018, Birmingham, AL 35238-5018
PCP phone: XXX.XXX.XXXX In 90%/10% Cigna Claims: PO Box XXXXX, Anytown, USA 12345-6789
ID card acct name 10 Out 3 70%/30% TPV Name, PO Box XXXXX, Anytown, USA 12345-6789 13
RxBIN XXXXXX RxPCN XXXXXXXX Med/Rx deductible applies CSN Name, PO Box XXXXX, Anytown, USA 12345-6789
DOI 9 Cat# Customer Service: 1-XXX-XXX-XXXX 14 MH/SA: 1-XXX-XXX-XXXX 15 AWAY FROM HOME CARE
PCP required Referral required Away from Home Care Out-of-network benefits
Encouraged No Yes Yes
For more information, see the next page.
Networks: HMO Open Access or POS Open Access
WWW.CIGNA.COM
CSN logo Client You may be asked to present this card when you receive care. The card does not guarantee coverage.
TPV logo
Tiered Benefits
2 logo You must comply with all terms and conditions of the plan. Willful misuse of this card is considered fraud.
12 INPATIENT ADMISSION or INPATIENT ADMISSION AND OUTPATIENT PROCEDURES:
Legal entity name
5 Your network provider must call the toll-free number listed below to pre-certify the above services. Refer to your plan documents
Coverage effective date: MM/DD/CCYY 7 POS (or HMO) Open Access for your pre-certif ication requirements. Failure to do so may af fect benef its. In an emergency, seek care immediately, then call your
No referral required primary care doctor as soon as possible for further assistance and directions on follow-up care within ### hours.
Group: 1234567
Issuer (80840) PCP Visit $15/$25 For information about mental health services and coverage, call 1-XXX-XXX-XXXX
Specialist 4 $15/$25 Med Group: Sunset Med Group 13
ID: U23456789 01 1
Name: John Public Hospital ER $50 Send Claims to: 123 Main Street, Suite 999, Anytown, USA 12345-6789
Urgent Care $25 For Dental call ABC Company 1-XXX-XXX-XXXX (not a Cigna Company)
PCP: James Smith 8 Vision Yes
PCP Name Ln2 For Vision call ABC Company 1-XXX-XXX-XXXX (not a Cigna Company)
Rx $10/20%/40%/100% Cigna Vision PO Box 385018, Birmingham, AL 35238-5018
PCP Phone: XXX.XXX.XXXX Rx Indiv Deduct $50 Cigna Claims: PO Box XXXXX, Anytown, USA 12345-6789
ID card acct name 10
Coinsurance applies 3
NSP TPV Name, PO Box XXXXX, Anytown, USA 12345-6789
RxBIN XXXXXX RxPCN XXXXXXXX logo 9 CSN Name, PO Box XXXXX, Anytown, USA 12345-6789
DOI Network Savings Program SAR Customer Service: 1-XXX-XXX-XXXX 14 MH/SA: 1-XXX-XXX-XXXX
PCP required Referral required Away from Home Care Out-of-network benefits
HMO Encouraged No No No
POS Encouraged No No Yes
For more information, see the next page.
2
Key
Managed care plans Refer to this key for explanations of the
information found on the sample Cigna ID cards
Managed care plans are designed to manage cost, utilization,
featured in this brochure.
and quality. Depending on the plan, customers may have
coverage for participating providers only, or have both 1 Use this ID number for all claims and inquiries.
in‑network and out‑of‑network benefits. Some plans require 2 Indicates a seamless network where a patient
referrals for specialty care and the selection of a primary care can receive in-network care on a regional or
provider (PCP). statewide basis.
Network: Network Open Access 3 For patients with coinsurance, submit claims
Plans that use this network offer customers access to participating to Cigna or its designee, and receive an
providers, with no referrals required. explanation of payment (EOP), which will show
any remaining amount due from the patient.
› Flexible plan designs allow for an array of cost-sharing options,
4 Collect any copayment at the time of service.
including copayments, coinsurance, and deductibles.
5 May read as: “Cigna Health and Life Insurance
› Customers can select a PCP to help coordinate care;
it’s recommended, but not required. Company” or “Connecticut General Life
Insurance Co.” or “Cigna HealthCare of
› Referrals are not required to see participating specialists.
XXXX, Inc.”
› Precertification may still be required for certain services
6 ID cards with the Cigna Care Network® logo
and procedures.
indicate the patient’s liability varies based
› No out-of-network coverage, except for emergencies.* on the provider’s Cigna Care designation
For a directory of providers who participate in this network, status. Refer to the online provider directory
visit Cigna.com > Find a Doctor. at Cigna.com > Find a Doctor to determine a
physician’s Cigna Care designation status.
Network: Open Access Plus
7 Effective date of coverage.
Plans that use this network offer customers access to a large,
8 Name of patient‘s primary care provider (PCP).
national network of providers. The plans include health advocacy
programs to help customers engage in wellness initiatives and 9 Network Savings Program (NSP) logo indicates
manage chronic conditions. that out-of-network discounts may be available
to the customer.
› Customers can select a PCP to help coordinate care;
10 Employer name.
it’s recommended, but not required.
› Referrals are not required to see specialists. 11 If a third party administers services in
› Precertification may still be required for certain services conjunction with Cigna, the ID card may
include multiple logos, and show a different
and procedures.
claim address or telephone number on the
For a directory of providers who participate in this network, back of the card.
visit Cigna.com > Find a Doctor.
12 Precertification requirements may be shown
Networks: Health Maintenance Organization (HMO) as either “Inpatient Admission” or “Inpatient
Open Access or Point of Service (POS) Open Access Admission and Outpatient Procedures.’’
Plans that use these networks offer customers access to local 13 Submit claims to the claim submission address
providers and a variety of different benefit options. The plans shown on the card.
include negotiated network-specific discounts and fee schedules, 14 Call the customer service number(s) indicated
along with robust medical management, to help reduce use of on the card. Some plans have dedicated
nonessential procedures. numbers for accessing information. Always
› Customers can select a PCP to help coordinate care; check the card for the correct number or refer
it’s recommended, but not required. to the Important contact information page in
this guide.
› Referrals are not required to see specialists.
15 “Away From Home Care” indicates the patient
› Precertification may still be required for certain services
and procedures. has access to the Cigna national Away From
Home Care feature.
For a directory of providers who participate in these networks,
visit Cigna.com > Find a Doctor. 16 Indicates shared administration repricing.
17 Union identifier.
* Emergency services as defined in their plan. 18 Client-specific network (CSN) logo.
3
4
MANAGED CARE PLANS (CONTINUED)
Networks: LocalPlus® or LocalPlusIN
CAD logo
WWW.CIGNA.COM
TPV logo 11 18 Client You may be asked to present this card when you receive care. The card does not guarantee coverage.
logo You must comply with all terms and conditions of the plan. Willful misuse of this card is considered fraud.
INPATIENT ADMISSION or INPATIENT ADMISSION AND OUTPATIENT PRECEDURES: 12
Legal entity name Your Network provider must call the toll-free number listed below to pre-certify the above services. Refer to your plan documents
Coverage effective date: MM/DD/CCYY for your pre-certification requirements. Failure to do so may affect benefits. In an emergency, seek care immediately, then call your
LocalPlus (or LocalPlusIN)
Group: 1234567 No referral required primary care doctor as soon as possible for further assistance and directions on follow-up care within ## hours.
Issuer (80840) PCP Visit $10 Carve out 1 Prt Line 13
ID: U23456789 01 1 Specialist $15 4 Carve out 2 Prt Line
Name: John Public Hospital ER $50
Urgent Care $25 Send claims to:
PCP: James Smith Vision Yes CAD Name, PO Box XXXX, Anytown, USA 12345-6789
Jane Smith Rx $10/20/30 TPV Name, PO Box XXXX, Anytown, USA 12345-6789
PCP Phone: 860.123.4567 Network coinsurance:
9 In 90%/10%
All Other: PO Box XXXX, Anytown, USA 12345-6789
ABC12 & Sons Company
Out 70%/30% Customer Service: 800.XXX.XXXX 14MH/SA: 800.XXX.XXXX
RxBIN XXXXXX RxPCN XXXXXXXX NSP
logo Med/Rx deductible applies We encourage you to use a PCP as a valuable resource and personal health advocate. Open Access Plus 15
DOI Label Network Savings Program Cat # AWAY FROM HOME CARE
PCP required Referral required Away from Home Care Out-of-network benefits
LocalPlus Encouraged No Yes Yes
LocalPlusIN Encouraged No Yes No
For more information, see the next page.
Networks: HMO, POS, or HMO POS
Select WWW.CIGNA.COM
2 Client
You may be asked to present this card when you receive care. The card does not guarantee coverage.
Preferred Hospital logo You must comply with all terms and conditions of the plan. Willful misuse of this card is considered fraud.
Legal Entity Name 5 12 INPATIENT ADMISSION or INPATIENT ADMISSION AND OUTPATIENT SERVICES
Your network provider must call the toll-free number listed below to pre-certify the above services.
Coverage Effective Date MM/DD/CCYY 7 HMO Refer to your plan documents for your pre-certification requirements. Failure to do so may affect
Group: 1234567 No Referred Required benefits. In an emergency, seek care immediately, then call your primary care doctor as soon as
Issuer (80840) PCP Visit $15 possible for further assistance and directions on follow-up care within ### hours.
Specialist $15
ID: U23456789 01 1 For information about mental health services and coverage, call XXX.XXX.XXXX
Name: John Public
Hospital ER 4 $50
MedGroup: Sunset Med Group
Urgent Care $25
PCP: James Smith 8 Vision Yes Send claims to: 123 Main Street, Suite 999, Anytown, USA 12345-678 13
PCP Name Ln2 Rx $10/20/40 For Pharmacy call ABC Company 1-XXX-XXX-XXXX (not a Cigna Company)
PCP Phone: XXX-XXX-XXXX Rx Indiv Deduct $50 For Vision call ABC Company 1-XXX-XXX-XXXX (not a Cigna Company)
ID Card Acct Name 10 Cigna Vision P.O. Box 385018, Birmingham, AL 32538/5018
Coinsurance Applies 3
RxBIN 017010 RxPCN 0215 COMM NSP
RxGroup: 1234567 logo 9 Cigna: PO Box XXXXX, Anytown, USA 12345-6789
DOI Label Network Savings Program Cat# Member Services: 1-XXX-XXX-XXXX MH/SA: 1-XXX-XXX-XXXX C
PCP required Referral required Away from Home Care Out-of-network benefits
HMO Yes Yes No No
POS Yes Yes No Yes
HMO POS Yes Yes No Yes
For more information, see the next page.
4
Key
Networks: LocalPlus® or LocalPlusIN Refer to this key for explanations of the
information found on the sample Cigna ID cards
Plans that use these networks offer customers access
featured in this brochure.
to participating providers in their local area, or in any
area in the country where one exists, for coverage at the 1 Use this ID number for all claims and inquiries.
in‑network cost.
2 Indicates a seamless network where a patient
› In areas where these networks are not available, can receive in-network care on a regional or
customers can access care through our Away From statewide basis.
Home Care feature for coverage at the in-network cost.
3 For patients with coinsurance, submit claims
› If customers choose to access care from providers to Cigna or its designee, and receive an
outside the LocalPlus network (or outside the Away explanation of payment (EOP), which will show
From Home Care feature when the LocalPlus network any remaining amount due from the patient.
isn’t available), they will likely pay more. (Customers
4 Collect any copayment at the time of service.
with the LocalPlusIN plan will pay the full cost of
their care.*) 5 May read as: “Cigna Health and Life Insurance
Company” or “Connecticut General Life
› Referrals are not required to see specialists.
Insurance Co.” or “Cigna HealthCare of
› Precertification may still be required for certain services XXXX, Inc.”
and procedures.
6 ID cards with the Cigna Care Network® logo
For a directory of providers who participate in these indicate the patient’s liability varies based
networks, visit Cigna.com > Find a Doctor. on the provider’s Cigna Care designation
status. Refer to the online provider directory
Networks: HMO, POS, or HMO POS
at Cigna.com > Find a Doctor to determine a
Plans that use these networks offer customers cost savings physician’s Cigna Care designation status.
and access to a local network of providers. 7 Effective date of coverage.
› Customers must select a network-participating PCP to 8 Name of patient‘s primary care provider (PCP).
coordinate care for coverage at the in-network cost.
9 Network Savings Program (NSP) logo indicates
› Referrals are required to see specialists except
that out-of-network discounts may be available
OB/GYNs.
to the customer.
› HMO POS plans include benefits and features similar to 10 Employer name.
HMO plans, plus out-of-network coverage at reduced
benefit levels. 11 If a third party administers services in
conjunction with Cigna, the ID card may
For a directory of providers who participate in these
include multiple logos, and show a different
networks, visit Cigna.com > Find a Doctor.
claim address or telephone number on the
back of the card.
12 Precertification requirements may be shown
as either “Inpatient Admission” or “Inpatient
Admission and Outpatient Procedures.’’
13 Submit claims to the claim submission address
shown on the card.
14 Call the customer service number(s) indicated
on the card. Some plans have dedicated
numbers for accessing information. Always
check the card for the correct number or refer
to the Important contact information page in
this guide.
15 “Away From Home Care” indicates the patient
has access to the Cigna national Away From
Home Care feature.
16 Indicates shared administration repricing.
17 Union identifier.
* Except for emergency services as defined by their plan.
18 Client Arranged Deal (CAD) network logo.
5
MANAGED CARE PLANS (CONTINUED)
Networks: Network or Network POS
18 WWW.CIGNA.COM
TPV logo
bl
11 CSN logo
2 Client You may be asked to present this card when you receive care. The card does not guarantee coverage. You must comply with all
Tiered Benefits 6 logo terms and conditions of the plan. Willful misuse of this card is considered fraud.
Legal entity name 5
12INPATIENT ADMISSION:
Your provider must call the toll-free number listed below to pre-certify the above services. Refer to your plan documents for your
Coverage effective date: MM/DD/CCYY 7 Network
pre-certification requirements. Failure to do so may affect benefits. In an emergency, seek care immediately, then call your primary
Group: 1234567 care doctor as soon as possible for further assistance and directions on follow-up care within ### hours.
Issuer (80840) PCP Visit $15/$20
Specialist 4 $15/$20 For information about mental health services and coverage, call MHSA Stmt Tel
ID: U23456789 01 1 Med Group: Sunset Med Group
Name: John Public Hospital ER $50
Urgent Care $25 Send claims to: 123 Main Street, Suite 999, Anytown, USA 12345-6789 13
PCP: James Smith 8 Vision Yes For Pharmacy, call ABC Company 800.XXX.XXXX (Not a Cigna Company)
PCP Name Ln2
Rx $10/20%/40%/100% For Vision, call ABC Company 800.XXX.XXXX (Not a Cigna Company)
PCP Phone: XXX.XXX.XXXX Rx Indiv Deduct $50 Cigna Claims: PO Box XXXX, Anytown, USA 12345-6789
ID card acct name 10 TPV Name, PO Box XXXX, Anytown, USA 12345-6789
RxBIN XXXXXX RxPCN XXXXXXXX Coinsurance applies 3 CSN Name, PO Box XXXX, Anytown, USA 12345-6789
DOI 9 OAP# bo
Customer Service: 800.XXX.XXXX 14MH/SA: 800.XXX.XXXX
PCP required Referral required Away from Home Care Out-of-network benefits
Network Yes Yes No No
Network Yes Yes No Yes
POS
For more information, see the next page.
Networks: PPO or EPO
SELF FUNDED NJ Arbitrations: YES WWW.CIGNA.COM
as of: MM/DD/CCYY
CAD or NBN logo 18 Client 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.
TPV LOGO 11 6 logo
Tiered Benefits 12 INPATIENT ADMISSION: or INPATIENT ADMISSION AND OUTPATIENT PROCEDURES:
Legal Entity Name 5
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
Coverage Effective Date: MM/DD/CCYY 7 PPO emergency, seek care immediately, then call your primary care doctor as soon as possible for further
Group: 1234567 Dr. Visit $15 assistance and directions on follow up care within ## hours.
Issuer (80840) Specialist $10/$25 Coinsurance/deductible is paid directly to the doctor/facility by Cigna using individual’s available health funds.
Hospital ER 4 $50
ID: U23456789 01 1 For Dental call ABC Company 1-XXX-XXX-XXXX (not a Cigna Company)
Urgent Care $25 For Vision call ABC Company 1-XXX-XXX-XXXX (not a Cigna Company)
Name: John Public Vision Yes Cigna Vision P.O. Box 385018, Birmingham, AL 35238-5018
Rx $10/20/30
Send Claims to:
ID Card Acct Name 10 13
Network Coinsurance: CAD Name, P.O. BOX XXXX, ANYTOWN, USA 12345-6789
9 In 90%/10%
3 70%/30% TPV Name, P.O. BOX XXXX, ANYTOWN, USA 12345-6789
RxBIN 017010 RxPCN 0215COMM Out
RxGroup: 1234567
NSP All Others: P.O. BOX XXXXX, ANYTOWN, USA 12345-6789
14 15
logo Med/Rx Deductible Applies Customer Service: 1-800-XXX-XXXX MH/SA: 1-800-XXX-XXXX AWAY FROM HOME CARE
DOI Label Network Savings Program Cat #
PCP required Referral required Away from Home Care Out-of-network benefits
PPO No No Yes Yes
EPO Encouraged No Yes No
For more information, see the next page.
6
Key
Networks: Network or Network POS Refer to this key for explanations of the
information found on the sample Cigna ID cards
Plans that use these networks offer customers cost
featured in this brochure.
savings, local convenience, and choice.
1 Use this ID number for all claims and inquiries.
› Customers must select a network-participating PCP to
coordinate care for coverage at the in-network cost. 2 Indicates a seamless network where a patient
can receive in-network care on a regional or
› Referrals are required to see specialists except
statewide basis.
OB/GYNs.
3 For patients with coinsurance, submit claims
› Network POS plans include benefits and features similar
to Cigna or its designee, and receive an
to Network plans, plus out-of-network coverage at
explanation of payment (EOP), which will show
reduced benefit levels.
any remaining amount due from the patient.
For a directory of providers who participate in these 4 Collect any copayment at the time of service.
networks, visit Cigna.com > Find a Doctor.
5 May read as: “Cigna Health and Life Insurance
Networks: PPO or Exclusive Provider Organization (EPO) Company” or “Connecticut General Life
Insurance Co.” or “Cigna HealthCare of
Plans that use these networks offer customers access to
XXXX, Inc.”
participating providers across the country.
6 ID cards with the Cigna Care Network® logo
PPO: indicate the patient’s liability varies based
› Both in- and out-of-network benefits are available. on the provider’s Cigna Care designation
› Customers can access services from providers who status. Refer to the online provider directory
at Cigna.com > Find a Doctor to determine a
do not participate in the network, but will assume
additional costs and be reimbursed at a lower physician’s Cigna Care designation status.
coinsurance level. 7 Effective date of coverage.
8 Name of patient‘s primary care provider (PCP).
EPO:
9 Network Savings Program (NSP) logo indicates
› No out-of-network coverage, except in emergencies.*
that out-of-network discounts may be available
› Referrals are not required to see network-participating
to the customer.
specialists.
10 Employer name.
For a directory of providers who participate in these
networks, visit Cigna.com > Find a Doctor. 11 If a third party administers services in
conjunction with Cigna, the ID card may
include multiple logos, and show a different
claim address or telephone number on the
back of the card.
12 Precertification requirements may be shown
as either “Inpatient Admission” or “Inpatient
Admission and Outpatient Procedures.’’
13 Submit claims to the claim submission address
shown on the card.
14 Call the customer service number(s) indicated
on the card. Some plans have dedicated
numbers for accessing information. Always
check the card for the correct number or refer
to the Important contact information page in
this guide.
15 “Away From Home Care” indicates the patient
has access to the Cigna national Away From
Home Care feature.
16 Indicates shared administration repricing.
17 Union identifier.
18 Client-specific network (CSN) or Client
* Emergency services as defined in their plan.
Arranged Deal (CAD) network logo.
7
MANAGED CARE PLANS (CONTINUED)
Network: Cigna SureFit®
Market-specific You may have to show this card when you receive care. This doesn’t guarantee coverage. Not
network name
In Network Only using this card correctly is fraud. For emergencies, call 911 or get immediate care. Contact your
Administered by Cigna Health and Life Insurance Company G
doctor after you get emergency services. If you don’t know if your situation is an emergency,
call your doctor or our 24/7 Health Information Line. Customers: Check your plan documents
for out-of-network (OON) precertification requirements. This may affect your OON benefits.
Group: 00699999 Health Care Professionals: Check your provider contract for precertification requirements.
Issuer (80840) Primary Care $25/0% Customers: myCigna.com
ID: 666666666 1 A Specialist $50/0%
Health Care Professionals: CignaforHCP.com
Name: John Doe Urgent Care $15/0%
PCP: Jeremiah B Johnson MD 8 ER Ded/20%
Referral Required Medical Claims PO Box 188061 Chattanooga, TN 37422-8061 Payer ID #62308 13
Hospital Ded/10%
Cigna SureFit HCA of the FrontRange
Rx Claims: Pharmacy Service Center, PO Box 188053, Chattanooga TN 37422-8053
RxBIN 017010 RxPCN 05180000 Customers & Health Care Professionals call 866-494-2111 14
RxGrp 00699999 RxID 222222222 00 For Pharmacists Only 800-351-9170
Mask 606 Issue Date: 10/25/17
Market-specific
WWW.CIGNA.COM
network name 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 or INPATIENT ADMISSION AND OUTPATIENT PROCEDURES:
Administered by Cigna Health and Life Insurance Company
Your network provider mst 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.
1 For pharmacy, call ABC Company 800.XXX.XXXX (Not a Cigna Company)
For vision, call ABC Company 800.XXX.XXXX (Not a Cigna Company)
8 Send claims to:
CAD name, PO Box XXXX, Anytown, USA 12345-6789 13
3 TPV name, PO Box XXXX, Anytown, USA 12345-6789
All others: PO Box XXXX, Anytown, USA 12345-6789
Customer service: 1-XXX.XXX.XXXX MH/SA: 1-XXX.XXX.XXXX 14
To find the market-specific network name that will appear on the ID card, refer to the table below. In the first
column, identify your market area. In the second column, you will see the corresponding market‑specific
network name that should appear on the Cigna SureFit ID card.
Market Market-specific network name
Arizona (Phoenix) with
and
affiliates
California (Southern California) Southern California
Central Florida (Orlando)
Colorado (Boulder, Denver, and Colorado Springs)
of the Front Range
Kansas and Missouri (Kansas City) Kansas City
Mid-Atlantic (Northern Virgina, Richmond and
Washington, DC)
Missouri (St. Louis)
South Florida South Florida
PCP required Referral required Away from Home Care Out-of-network benefits
Yes Yes No No
For more information, see the next page.
8Key
Network: Cigna SureFit® Refer to this key for explanations of the
information found on the sample Cigna ID cards
Plans that use this network offer customers access
featured in this brochure.
to local physician and hospital groups for personal,
patient‑centered care. 1 Use this ID number for all claims and inquiries.
› Customers must select a network-participating PCP 2 Indicates a seamless network where a patient
to coordinate their care. can receive in-network care on a regional or
› Referrals are required to see specialists. statewide basis.
› No out-of-network coverage or Away From Home Care, 3 For patients with coinsurance, submit claims
except in emergencies.* to Cigna or its designee, and receive an
For a directory of providers who participate in these explanation of payment (EOP), which will show
networks, visit Cigna.com > Find a Doctor. any remaining amount due from the patient.
4 Collect any copayment at the time of service.
5 May read as: “Cigna Health and Life Insurance
Company” or “Connecticut General Life
Insurance Co.” or “Cigna HealthCare of
XXXX, Inc.”
6 ID cards with the Cigna Care Network® logo
indicate the patient’s liability varies based
on the provider’s Cigna Care designation
status. Refer to the online provider directory
at Cigna.com > Find a Doctor to determine a
physician’s Cigna Care designation status.
7 Effective date of coverage.
8 Name of patient‘s primary care provider (PCP).
9 Network Savings Program (NSP) logo indicates
that out-of-network discounts may be available
to the customer.
10 Employer name.
11 If a third party administers services in
conjunction with Cigna, the ID card may
include multiple logos, and show a different
claim address or telephone number on the
back of the card.
12 Precertification requirements may be shown
as either “Inpatient Admission” or “Inpatient
Admission and Outpatient Procedures.’’
13 Submit claims to the claim submission address
shown on the card.
14 Call the customer service number(s) indicated
on the card. Some plans have dedicated
numbers for accessing information. Always
check the card for the correct number or refer
to the Important contact information page in
this guide.
15 “Away From Home Care” indicates the patient
has access to the Cigna national Away From
Home Care feature.
16 Indicates shared administration repricing.
17 Union identifier.
* Emergency services as defined in their plan.
18 Client-specific network (CSN) logo.
910
0000002 251 116 03040 9090436 0000 0000002 0000001 252 117 03040 9091187 0000 0000001
NAME
0000002 251 116 03040 9090436 0000 0000002 0000001 252 117 03040 9091187 0000 0000001
DOC_ID
UHG_TYPE
DOE
RUN_DATE
Name:
CUST_KEY1
CUST_KEY2
CUST_KEY3
CUST_KEY4
CUST_KEY5
CUST_KEY6
CUST_KEY7
CUST_KEY8
CUST_KEY9
NAME
DOC_SEQ_ID M
DOC_ID
00
JOHN
Name: JOHN
CHICAGO,
JOHN DOE
JOHN DOE
DATA_SEQ_NO
ORLANDO,
Cigna Health
PCP: Jessica A.PCP:
Issuer (80840)
Issuer (80840)
DOE
CLIENT_NUMBER
UHG_TYPE
Cigna
DOE
Florida Connect
RUN_DATE
Doright
Name:
Name:
JOHN
Group: 00881700
CUST_KEY1
CUST_KEY2
CUST_KEY3
CUST_KEY4
CUST_KEY5
CUST_KEY6
CUST_KEY7
CUST_KEY8
CUST_KEY9
Group: 00881200
Referral Required
Cigna HealthCare
MAILSET_NUMBER
ID: 234567891
E DOE
ID: 456789123
RxBIN 017010
RxBIN 017010
RxGrp 00881700
Jessica
RxGrp 00881200
M DOE
DOC_SEQ_ID
APT 999APT 999
Cigna PlusCigna Plus
M
No ReferralNoRequired
Medical/RxMedical/Rx
9999 W FARWELL
Medical/RxMedical/Rx
00
CHICAGO,
9999 SPINDLETOP
20200907
USPS
JOHN DOE
JOHN DOE
DATA_SEQ_NO
DIG1CARD
00881700
ORLANDO,
andHealth
Issuer (80840)
Issuer (80840)
0000002
DOE
234567891
FL 32819
CLIENT_NUMBER
09/02/2020
>000002 9090436 003040 03040
Florida Connect
DR
JOHN
Group: 00881700
AVE
Group: 00881200
0000002
Referral Required
Cigna HealthCare
003040
MAILSET_NUMBER
ID: 234567891
JOHN E DOE
ID: 456789123
RxBIN 017010
RxBIN 017010
RxGrp 00881700
RxGrp 00881200
No*
No*
JOHN M DOE
DOA. Doright DO
1
1
of Illinois, of
*PCP selection
00000000
00000000
Referral Required
9999 W FARWELL
9999 SPINDLETOP
Life Insurance
20200907
0000002
USPS
DIG1CARD
00881700
9090436/000002-00
9090436/000002-01
9090436/000002-02
IL 60626IL 60626
0000002
234567891
FL 32819
09/02/2020
>000002 9090436 003040 03040
DR
12:45:50
AVE
,JOHN
0000002
PCP required
PCP required
*PCP selectionDIRECT
003040
on your ID card.
00000000
00000000
Inc.Illinois, Inc.
and Life Insurance
0000002
RxID 234567891
RxID 456789123
our website or call the toll-free customer service number located e number located
9090436/000002-00
9090436/000002-01
9090436/000002-02
RxPCN 0518GWH
RxPCN 0518GWH
8
8
• If you have questions or to elect or change your PCP, please visit r PCP, please visit
12:45:50
,JOHN
00
00
DIRECT DIRECT
andDIRECT
• Present ID card each time you visit a health care professional.
ID card.
on your this h care professional.
ER
ER
Company Company
RxID 234567891
RxID 456789123
our website or call the toll-free customer service number located e number located
RxPCN 0518GWH
• If you have questions or to elect or change your PCP, please visit RxPCN 0518GWH r PCP, please visit
00
• Present this ID card each time you visit a health care professional. 00 h care professional.
Urgent Care
Urgent Care
Primary Care
Primary Care
Lorem
Urgent
Urgent
Primary
Primary
Hospital Hospital
Hospital Hospital
Specialist Specialist
$50-0%
$60-0%
Specialist Specialist
Ded-50%
ER Ded-50%
Ded-50%
Ded-50%
Ded-50%
Care
Care
Lorem
No*
No*
ipsum
Care $50-0%
$60-0%
$25-0%Care $25-0%
Ded-50%
Ded-50%
Ded-50%
Ded-50%
Ded-50%
Ded-20% Ded-20%
ER Ded-$600-0%Ded-$600-0%
3
3
ipsum
Referral required
Referral required
4
4
G
G
(Market Name)
1 00500-0005-L 1 00500-0005-L
G
G
Connect (Market Name)
USPS USPSand referrals are required only in Illinois.
referrals are required only in Illinois.
1 00500-0005-L 1 00500-0005-L
606
606
What does it mean? What do
N
N Ded/Coin - Subject to the plan deductible and/or coinsurance Ded/Coin - Subject to t
Network: Connect
No
No
For Premium,
For Premium,
Medical Claims
Medical Claims
For BenefitFor
For BenefitFor
Network: Cigna Plus
plan deductible pla
and
and
For Pharmacists
For Pharmacists
606
606
Ded - SubjectWhat to thedoes it mean? amount Ded - SubjectWhat to thedo
Medical
Medical
ForBilling
ForBilling
Coin - Subject to the plan coinsurance amount Coin - Subject to the pl
Rx Claims RxPharmacy
Rx Claims RxPharmacy
N
N
Ded/Coin - Subject to the plan deductible and/or coinsurance
Benefit
Ded/Coin - Subject to t
Benefit
20200907
20200908
Tue Sep Tue
Premium,
Premium,
Copay - Subject to the copayment amount Copay - Subject to the c
PO Claims
PO Claims
Mon SepMon
INDIVIDUAL & FAMILY PLANS
Ded - Subject to the plan deductible amount Ded - Subject to the pla
Claim and
Claim and
For Pharmacists
For Pharmacists
Claims Service
Box 188061
Claims Service
Box 188061
Physician PCP Phys
08, 2020
PCP --Primary
Coin Subject Care
to the plan coinsurance amount Coin--Primary
Subject Care
to the pl
07, 2020
Away from Home Care
Away from Home Care
Pharmacy
Pharmacy
questions
questions
Urgent - After hours/urgent Urgent - After
Sep 08,
20200907
20200908
and Enrollment
and Enrollment
Sep 07,
Copay -CareSubject to the copaymentcare amount Copay -CareSubject to the
houc
For more information, see the next page.
Center,
Center,
ER - Emergency Room
Only: 800-351-9170
ER - Emergency Room
Only: 800-351-9170
Service
Service
POChattanooga, PCP - Primary Care Physician PCP - Primary Care Phys
POChattanooga,
Hospital or Hospital Stay - Inpatient hospital Hospital or Hospital Sta
PO Box
PO Box
Claim questions
Claim questions
Urgent Care - After hours/urgent care Urgent Care - After hou
@ 11:30:45
Center,
Rx- Pharmacy
Center,
Rx- Pharmacy
@ 12:45:50
please call:
ER - Emergency Room ER - Emergency Room
Only: 800-351-9170
Only: 800-351-9170
188053,
188053,
THE FOLLOWING NOTICE APPLIES TO CUSTOMERS COVERED UNDER LOUISIANA PLANS THE FOLLOWING NOTICE APPLIES T
Box 188061 Chattanooga,
please
Box 188061 Chattanooga,
Hospital Hospital Stay - Inpatient hospital Hospital Hospital Sta
PO Box
NOTICE: YOURor
SHARE OF THE PAYMENT FOR HEATHCARE SERVICE MAY BE BASED ON
PO Box
NOTICE: YOURor
SHARE OF THE PAYM
TN 37422-8061
TN 37422-8061
THE AGREEMENT BETWEEN YOUR HEALTH PLAN AND YOUR PROVIDER. UNDER CERTAIN THE AGREEMENT BETWEEN YOUR H
2020 @ 11:30:45
Rx- Pharmacy Rx- Pharmacy
2020 @ 12:45:50
CIRCUMSTANCES, THIS AGREEMENT MAY ALLOW YOUR PROVIDER TO BILL YOU FOR CIRCUMSTANCES, THIS AGREEMENT
TN Payer
TN Payer
Billing and EnrollmentQuestions please
Billing and EnrollmentQuestions please
AMOUNTS
THE FOLLOWING THE PROVIDER'S
UP TONOTICE REGULAR
APPLIES TO BILLED
CUSTOMERS CHARGES.
COVERED UNDER LOUISIANA PLANS AMOUNTS
THE FOLLOWING THE PROVIDER'S
UP TONOTICE APPLIES TR
Chattanooga
Chattanooga
pleasecall: 1-866-494-2111
NOTICE: YOUR SHARE OF THE PAYMENT FOR HEATHCARE SERVICE MAY BE BASED ON NOTICE: YOUR SHARE OF THE PAYM
Questions
Questions
37422-8061
37422-8061
Mask 606Mask 606
Mask 606Mask 606
THE AGREEMENT BETWEEN YOUR HEALTH PLAN AND YOUR PROVIDER. CERTAIN
1-866-494-2111
'Cigna' and the 'Tree of Life' logo are registered service marks
UNDERof THE AGREEMENT BETWEEN YOUR H
'Cigna' and the 'Tree of Life' l
ID #62308
ID #62308
CIRCUMSTANCES, THIS AGREEMENT MAY ALLOW YOUR PROVIDER TO BILL YOU FOR CIRCUMSTANCES, THIS AGREEMENT
Cigna
AMOUNTSIntellectual
UP TO THE PROVIDER'S Inc., licensed
Property,REGULAR BILLED for use by Cigna Corporation
CHARGES. Cigna
AMOUNTSIntellectual
UP TO THE PROVIDER'S
Property,RI
188053, Chattanooga
188053, Chattanooga
pleasecall: 1-866-494-2111
and its operating subsidiaries. All products and services are provided by or through and its operating subsidiarie
TN 37422-8053
TN 37422-8053
such operating subsidiaries Cigna Corporation. Such
call: 1-866-494-2111
such operating subsidiaries
call: 1-877-900-1237
call: 1-877-484-5967
'Cigna' and the 'Tree of Life' and
logonotareby registered service marks of operating 'Cigna' and the 'Tree of Life' l
Payer ID #62308
Payer ID #62308
subsidiaries include Connecticut Insurance Company (CGLIC) subsidiaries include
No
No
Cigna Intellectual Property, Inc., licensed
General forLifeuse by Cigna Corporation Cigna Intellectual Property,
ConnectI
Cigna Health and Life Insurance (CHLIC), Cigna Health Management, Cigna Health and Life Insura
14
14
and its operating subsidiaries. All products and services are providedInc. by or through and its operating subsidiarie
13
13
TN 37422-8053
TN 37422-8053
and Cigna Dental Health, Inc. The Cigna Dental PPO is underwritten
such operating subsidiaries and not by Cigna Corporation. Such operating or administered and Dental Health, Inc
suchCigna
operating subsidiaries
please call: 1-877-900-1237
please call: 1-877-484-5967
by CGLIC or CHLIC
subsidiaries includewith network management
Connecticut services provided
General Life Insurance Cigna
Companyby(CGLIC) by CGLIC or CHLIC netw
subsidiaries includewith
Connect
Dental
Cigna Health
Health,and and
Inc.,Life Insurance its operating
certain of(CHLIC), subsidiaries.
Cigna Health Management, and
In ArizonaInc. Dental Health, Inc., and certa
Cigna Health and Life Insura
Issue Date:Issue
Issue Date:Issue
Louisiana,
and Cigna the insured
Dental Health, Dental
Inc. The product
PPOCigna is referred
Dental PPO isto as the 'CG Dental
underwritten PPO'
or administered Louisiana, insured Denta
and Cigna the
Dental Health, Inc
*116*
(CGLIC) or 'CH Dental PPO' (CHLIC). In Texas, the insured
by CGLIC or CHLIC with network management services provided by Cigna dental product offered (CGLIC) or 'CH Dental PPO' (C
by CGLIC or CHLIC with netw
09/07/20
09/08/20
Out-of-network benefits
Out-of-network benefits
by CGLIC
Dental and CHLIC
Health, is referred
Inc., and certain to
of as
its the 'Cigna Dental
operating subsidiaries.
ChoiceInPlan'.
Arizona and by CGLIC and CHLIC is referr
Dental Health, Inc., and certa
The Cigna Dental
Louisiana, PPO Network(s)
the insured a national
Dental PPOisproduct reference
is referred to as
to the network;
our 'CG Texas
DentalinPPO' The Cigna Dental PPO Netw
Louisiana, the insured Denta
*116*
this network(s)
(CGLIC) or 'CH Dental utilized
will bePPO' (CHLIC).
with IntheTexas,
Cignathe Dental Choice
insured dentalPlan
product offered this network(s) utilize
(CGLIC) or 'CH Dental
will bePPO' (C
Date: 09/07/20
Date: 09/08/20
by CGLIC and CHLIC is referred to as the 'Cigna Dental Choice Plan'. by CGLIC and CHLIC is referr
The Cigna Dental PPO Network(s) is a national reference to our network; in Texas The Cigna Dental PPO Netw
this network(s) will be utilized with the Cigna Dental Choice Plan this network(s) will be utilizeKey
Individual & Family Plans Refer to this key for explanations of the
information found on the sample Cigna ID cards
Cigna offers Individual & Family Plans with medical, pharmacy,
featured in this brochure.
and (when applicable) pediatric dental benefits in Arizona,
Colorado, Florida, Illinois, Kansas, Missouri, North Carolina, 1 Use this ID number for all claims and inquiries.
Tennessee, Utah, and Virginia. Depending on the plan, 2 Indicates a seamless network where a patient
customers will have access to providers who participate in our can receive in-network care on a regional or
Connect network. The network name will appear on the top statewide basis.
right of the ID card.
3 For patients with coinsurance, submit claims
Network: Connect to Cigna or its designee, and receive an
Plans that use this network offer customers access to providers in explanation of payment (EOP), which will show
their local area. any remaining amount due from the patient.
4 Collect any copayment at the time of service.
› Customers do not have to select a PCP but are encouraged to
coordinate their care with a network-participating PCP. 5 May read as: “Cigna Health and Life Insurance
› Referrals are encouraged but not required to see specialists. Company” or “Connecticut General Life
› No out-of-network coverage or Away From Home Care, except Insurance Co.” or “Cigna HealthCare of
XXXX, Inc.”
in emergencies.**
For a directory of providers who participate in this network, 6 ID cards with the Cigna Care Network® logo
visit Cigna.com/IFP-Providers. indicate the patient’s liability varies based
on the provider’s Cigna Care designation
Network: Cigna Plus status. Refer to the online provider directory
Plans that use this network offer customers access to providers in at Cigna.com > Find a Doctor to determine a
their local area. physician’s Cigna Care designation status.
› Customers must select a network-participating PCP 7 Effective date of coverage.
to coordinate their care.* 8 Name of patient‘s primary care provider (PCP).
› Referrals are required to see specialists.* 9 Network Savings Program (NSP) logo indicates
› No out-of-network coverage or Away From Home Care, except that out-of-network discounts may be available
in emergencies.** to the customer.
For a directory of providers who participate in this network, 10 Employer name.
visit Cigna.com/IFP-Providers. These listings will be available and
11 If a third party administers services in
labeled as “Cigna Plus” within the network selection options.
conjunction with Cigna, the ID card may
include multiple logos, and show a different
claim address or telephone number on the
back of the card.
12 Precertification requirements may be shown
as either “Inpatient Admission” or “Inpatient
Admission and Outpatient Procedures.’’
13 Submit claims to the claim submission address
shown on the card.
14 Call the customer service number(s) indicated
on the card. Some plans have dedicated
numbers for accessing information. Always
check the card for the correct number or refer
to the Important contact information page in
this guide.
15 “Away From Home Care” indicates the patient
has access to the Cigna national Away From
Home Care feature.
16 Indicates shared administration repricing.
17 Union identifier.
* PCP selection and referrals are required in Illinois.
** Emergency services as defined in their plan. 18 Client-specific network (CSN) logo.
11MEDICARE PLANS
Network: Prescription Drugs
This cardThis
doescard
not does
guarantee
not guarantee
coveragecoverage
or payment.
or payment.
[Services may
[Services
requiremay
[a referral
require or]
[a referral
[an] authorization
or] [an] authorization
by the Health
by the
Plan.]
Health Plan.]
Medicare limiting
Medicarecharges
limitingapply.
charges apply.7
Name Name Customer
Customer
711)
(TTY 711)
ID ID [Provider[Provider
Services Services]
]
Health Plan
Health(80840)
Plan 1 (80840) 5
3
[Authorization[/Referral]
[Authorization[/Referral]
]
]
[Effective[Effective
Date ] [Provider[Provider
Medical Claims Claims ] 6
Medical]
RxBIN
RxBIN [Pharmacy[Pharmacy
Help DeskHelp Desk
]
]
[No PCP Required]
[No PCP Required] RxPCN
RxPCN [Pharmacy[Pharmacy
Claims Claims] ]
[No Referral
[NoRequired]
Referral Required]
COPAYS COPAYS 4
RxGRP RxGRP [Dental Services
[Dental Services ]
]
PCP PCP SpecialistSpecialist
[Provider[Provider
Dental Claims
Dental Claims
]
]
Emergency
Emergency
Urgent care
Urgent care
INT_21_89795_C
INT_21_89795_C
This card isThis
usedcard
for isallused
Truefor
Choice
all True
plans.
Choice plans. Network: Medicare Advantage
This cardThis
doescard
not does
guarantee
not guarantee
coveragecoverage
or payment.
or payment.
[Services may
[Services
requiremay
[a referral
require or]
[a referral
[an] authorization
or] [an] authorization
by the Health
by the
Plan.]
Health Plan.]
Name Name
[Medicare limiting
[Medicarecharges
limitingapply.]
charges apply.]7
ID ID
Health Plan Plan 1 (80840)
Health(80840) 3 [Customer
[Customer
711)]
(TTY 711)]
[Effective[Effective
Date ] [Provider[Provider
Services Services
]
]
PCP PCP 3 [Authorization[/Referral]
[Authorization[/Referral]
]
]
Part B Drugs
Part B Drugs 6
PCP Phone PCP Phone
[Provider[Provider
Medical Claims
Medical Claims ]
]
[RxBIN [RxBIN
]]
PCP Network
PCP Network
[Dental Services
[Dental Services]
]
[RxPCN [RxPCN
]]
[Provider[Provider
Dental Claims
Dental]
Claims ]
[No Referral
[NoRequired]
Referral Required]
COPAYS COPAYS [RxGRP
4 [RxGRP]]
[Pharmacy[Pharmacy
Help DeskHelp ]
]
PCP PCP SpecialistSpecialist
Urgent Care
Urgent
Care [] []
Emergency
Emergency
INT_21_89709_C
INT_21_89709_C
This card is This
usedcard
for non-TrueChoice
is used for non-TrueChoice
MA Only plans.
MA Only plans.
Network: PPO
This cardThis
doescard
not does
guarantee
not guarantee
coveragecoverage
or payment.
or payment.
[Services may
[Services
requiremay
[a referral
require or]
[a referral
[an] authorization
or] [an] authorization
by the Health
by the
Plan.]
Health Plan.]
Name Name
[Medicare limiting
[Medicarecharges
limitingapply.]
charges apply.]7
ID ID
Plan 1 (80840)
Health(80840)
Health Plan 3
5 [Customer
[Customer
711)]
(TTY 711)]
Date ] Date>] [
DateKey
Medicare Plans Refer to this key for explanations of the
information found on the sample Cigna ID cards
Cigna contracts with the Centers for Medicare & Medicaid
featured in this brochure.
Services (CMS) to offer Medicare Advantage (MA) plans.
Customers are able to select one of several plans offered 1 Use this ID number for all claims and inquiries.
based on their location, budget and health care needs. 2 Effective date of coverage.
For more information and to access the directory of 3 Name of patient‘s primary care provider (PCP).
participating providers, visit Medicareproviders.cigna.com. 4 Collect any copayment at the time of service.
5 Prescription Drug Coverage.
6 Submit claims to the claim submission address
shown on the card.
7 Call the customer service number(s) indicated
on the card. Some plans have dedicated
numbers for accessing information. Always
check the card for the correct number.
13MEDICAID PLANS
Medicaid Eligible Only
1
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For more information, see the next page.
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