Policy Disclosures for Arizona

Rates will vary by plan design including the amount of plan deductibles, coinsurance, and out-of-pocket and lifetime maximums. Rates may vary based on age, gender, geographic location and the plan deductible selected.

Rates are guaranteed for a rating period of twelve months effective when the insurance policy is issued with the exception of any policy amendment activities, such as any benefit changes, switching to a different plan, adding or dropping dependents and moving to a different rating area. Eligibility for rate is based upon residential zip code. After the initial guarantee, rates are subject to change upon 60 days prior notice for individuals enrolled in Cigna HealthCare of Arizona, Inc., and upon 30 days prior notice for individuals insured by Connecticut General Life Insurance Company.

These rates are the Cigna standard rates. Enrollment in a Cigna Open Access, Open Access Value Health Savings Plan is subject to medical underwriting guidelines established by the health plan, and your rate may vary based upon the results of the medical underwriting risk assessment process. You may be declined coverage because of a health condition. If you are issued a policy, certain medical conditions may not be covered for a specified length of time if those conditions are related to a medical condition that existed prior to the date of coverage. These medical and dental insurance policies and General Service Agreement have exclusions, limitations, reduction of benefits and terms under which the policy may be continued in force or discontinued.

GENERAL EXCLUSIONS AND LIMITATIONS, EXCEPT AS SPECIFICALLY REQUIRED BY LAW:
Services that are: not medically necessary; not a covered benefit; experimental or investigational; conditions caused by or contributed by an act of war, insurrection, riot, military service; work-related injuries or conditions that can be covered under a workers’ compensation or similar policy; services that may be obtained from a local, state, or federal agency (except Medicaid); professional services or supplies received from yourself, a family member, or other person living in your home. Private duty nurse; private hospital room; hospital stays primarily for environmental change, diagnostic tests, and physical therapy for treatment of chronic pain. Stays in a nursing or rest home; normal pregnancy and maternity benefits; custodial care; personal and comfort items; orthodontic services; optometric services; eye surgery to correct refractive defects of the eye; non-prescription contraceptive drugs, devices, or supplies; cosmetic surgery/ services; sex change surgery; treatment for sexual dysfunction, fertility, or infertility; animal to human organ transplants; orthopedic shoes; orthotics; routine foot care; weight reduction or treatment of obesity; telephone or e-mail consultations; cryopreservation; hearing aids; dental implants; smoking cessation aids; non-emergency foreign country providers; educational or nutritional services; durable medical equipment not specifically listed as Covered Services. Pharmacy exclusions include: immunizing agents; biological sera; blood and blood products; drugs associated with weight loss; allergy desensitization products or serum; drugs obtained outside the United States; and growth-hormone treatment. In addition, no benefits are provided for the following: dental services: services performed primarily for cosmetic reasons except as described in the Dental Benefits Policy: replacement of a lost or stolen appliance; initial placement of a full or partial denture unless it includes the replacement of a functioning natural tooth extracted while the person is covered under this plan; removal of only a permanent third molar will not qualify for an initial or replacement denture or bridge; overdentures, personalization, precision or semi-precision attachments; replacement of a bridge, denture or crown within 84 months following its initial date of insertion; replacement of a bridge, denture or crown which can be made useable according to dental standards; procedures, appliances or restorations, other than full dentures, whose main purpose is to change vertical dimension, diagnose or treat conditions of TMJ, stabilize periodontally involved teeth, or restore occlusion, the restoration of teeth which have been damaged by erosion, attrition or abrasion; bite registration; or bite analysis; veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and third molars; core buildup, labial veneers; precious or semi-precious metals for crowns, bridges, pontics and abutments; crowns and bridges other than stainless steel or resin for participants under 16 years old; bite registrations; precision or semi-precision attachments; splinting; surgical implant of any type; instruction for plaque control, oral hygiene and diet; Prosthesis Over Implant-a prosthetic device, supported by an implant or implant abutment; dental services that do not meet common dental standards; services that are deemed to be medical services; services and supplies received from a hospital; procedures for which a charge would not have been made in the absence of coverage, for which the person is not legally required to pay; procedures which do not have uniform professional endorsement; charges in excess of the reasonable and customary allowances; amounts in excess of Maximum Reimbursable Charges; IV sedation or general anesthesia, except when medically or Dentally Necessary and when in conjunction with covered complex oral surgery; fees charged for broken appointments, claim form submission or sterilization; services not included in the list of covered dental expenses, unless Cigna agrees to accept such expense as a covered dental expense, in which case payment will be made consistent with similar services which would provide the least expensive professionally satisfactory result; crowns, inlays, cast restorations, or other laboratory prepared restorations on teeth unless the tooth cannot be restored with an amalgam or composite resin filling due to major decay or fracture; replacement of teeth beyond the normal complement of 32; prescription drugs; athletic mouth guards; myofunctional therapy; charges for travel time; transportation costs; or professional advice given on the phone; any procedure, service, or supply which may not reasonably be expected to successfully correct the covered person’s dental condition for a period of at least three years, as determined by Cigna; temporary, transitional or interim dental services; diagnostic casts, diagnostic models, or study models; any charge for any treatment performed outside of the United States other than for Dental Emergency Services (limited to a maximum of $100.00 per 12 consecutive month period); procedures that are a covered expense under any other dental plan which provides dental benefits whether or not on an insured basis; any charges, including ancillary charges, made by hospital, ambulatory surgical center or similar facility; to the extent that payment is unlawful where the person resides when the expenses are incurred; for charges which would not have been made if the person had no insurance of for unnecessary care, treatment or surgery.