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CIGNA Exclusive Provider Organization (EPO)
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Visit a doctor — without a referral
CIGNA Exclusive Provider Organization (EPO) plans offer access to our broad provider networks, and let you make your own health care choices. For example:
- Members can see any participating physician in our network, any time.
- Members have the freedom to visit any in-network specialist without a referral.
- During an emergency or urgent care situation, a member also may receive approval to use out-of-network services.
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Where to Find the Care You Need
Here is a summary of your plan's services and how to arrange for care.
Routine Medical Care (such as physical exams, mild fever and pains, chronic pain and, headaches, colds and flu)
- Call your personal physician's office during office hours and he or she will provide you with medical advice and/or schedule an office visit for you.
- If your physician is in our network, your services will be covered.
Specialty Care (such as orthopedic or heart disease)
- Make an appointment with a specialist for an initial assessment and if needed, he or she will provide medical advice and treatment.
- If your physician is in our network, your services will be covered.
Hospital Care (such as inpatient care and surgery, or outpatient surgery)
- For non-emergency care, call CIGNA HealthCare for approval and someone will work with you to coordinate all your hospital care.
- If the health care facility is in our network, your services will be covered.
Urgent Medical Care (such as fever, sprains or strains, eye or ear infections, or severe sore throat)
- Call your personal physician. He or she will assess your situation and if necessary, give you advice on where to seek immediate care.
- During an urgent care situation, you also may receive approval to use out-of-network services.
Emergency Care (such as poisoning, chest pains, broken bones, uncontrolled bleeding, loss of consciousness or sudden paralysis)
- During an emergency situation, you may receive approval to use out-of-network services. Go to the nearest emergency facility or call 911. Call CIGNA HealthCare as soon as reasonably possible and your personal physician will coordinate all follow-up care.
Next (Cost Example) >
How an EPO might work for you
You choose a CIGNA physician and set up an appointment for a wellness exam. Your physician orders some lab tests to check your cholesterol.
| Cost Example |
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| PCP office visit/exam fee |
$85 |
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| Your copayment |
$20 |
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| Independent lab fee |
$250 |
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| You pay |
$250 |
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| You meet your $250 deductible |
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Next (Special Programs) >
Health and wellness programs
Members of CIGNA HealthCare plans may also have access to valuable Health and Wellness Programs:
- Well Informed — a personalized health improvement program designed to let CIGNA HealthCare members and their doctors know about opportunities to maintain or improve the member's health.
- 24-hour health information — call the CIGNA HealthCare 24-Hour Health Information LineSM any time to speak with a registered nurse or listen to our audio library for health-related information.
- Support for chronic conditions — manage your asthma, diabetes, heart condition, low back pain, or chronic obstructive pulmonary disease with help from CIGNA Well Aware for Better Health®.
- Member discounts — save up to 60% on products and services-from acupuncture to weight management-with our Healthy Rewards® discount program. Note: not all programs are available in all states.
- Quality transplant care — access care from nationally recognized facilities in the CIGNA LIFESOURCE Transplant Network®.
- CIGNA HealthCare Healthy Babies® — give your child a healthy beginning with information and support from the CIGNA HealthCare Healthy Babies® program.
- CIGNA Healthy Pregnancies, Healthy BabiesSM — the CIGNA Healthy Pregnancies, Healthy Babies® program offers a full scope of educational and care management services to members who are pregnant or considering pregnancy.
- Cancer prevention and education — the Comprehensive Oncology Program® addresses cancer prevention and education, as well as active management of members diagnosed with cancer.
- High Touch Personal Assistance — with CIGNA Health AdvisorSM, CIGNA Health Advisors proactively identify and reach out to members who are at risk for significant health issues but are not appropriate candidates for chronic or acute disease or case management programs.
- Lose weight and improve your health — when you enroll in the CIGNA Healthy Steps to Weight LossSM, you won't be starting a diet. Instead, this program helps you change your behaviors permanently. You'll learn healthier eating habits and how to incorporate exercise into your schedule – helping you to feel better, look better and improve your overall health.
Check your plan materials or log in to myCIGNA for more information about your EPO plan, including your eligibility for specific programs and services. Or ask your employer or benefits manager for more information about enrolling in a CIGNA HealthCare plan.
Next (Employer Advantages - Benefits) >
Employer Advantages
The CIGNA HealthCare EPO provides your employees with referral-free access to participating physicians. Your employees also have the option to choose out-of-network coverage; however, there are no out-of-network benefits except in emergency or urgent care situations.
The flexible plan designs also include:
- no primary care physician (PCP) selection requirement;
- customized cost-sharing choices-deductibles, coinsurance and plan maximums;
- multiple funding options;
- our Network SavingsSM Program—provides discounts for services provided by certain out-of-network physicians, hospitals and other facilities;
- consolidated billing, accounting, reporting and banking; and
- standard health and wellness features, with optional features available at an additional cost.
Next (Support) >
We've designed a flexible communication program to help your employees understand their plan and make better health care purchase decisions.
Pre-enrollment
- optimum communications time line and approach
- implementation plan
- introductory letter from your CEO/President or benefits administrator
- customized Intranet articles
- newsletter articles
- e-mail notices
- presentation scripts
- posters
- payroll stuffers
- "train the trainers" presentation
Open enrollment
- enrollment kits
- toll-free help line
- benefit fair
- kiosk (at an additional cost)
- on-site enrollers, workshops and seminars
Post-enrollment
- handbook
- monthly e-mail copy
- customized Intranet services with online forms and detailed information about your company's plan
- customized, secure employee portal, myCIGNA, with extensive, reliable health information from Web MD®, physician and hospital ratings, side-by-side drug comparisons and health records and trackers
Your implementation manager will help you every step of the way with communication strategies and materials that best suit you and your employees.
Next (Options) >
Funding Options
Choose from multiple funding options:
Fully Insured
- Full premium paid monthly
- Predetermined and guaranteed rates
- Predictable, easy-to-budget expenses
- Protection from high claim costs
Fully Insured - Participating
- Full premium paid monthly
- Predetermined and guaranteed rates
- Predictable, easy-to-budget expenses
- Protection from high claim costs
- Year-end settlement
- Can earn cash back at year end if claims are low
Minimum Premium
- Lower premium paid monthly
- Claims funded through bank account with a monthly claim cap
- Protection from high claim costs
- Year-end settlement
- Improved cash flow
- Lower expenses and premium taxes
Administrative Services Only
- No monthly premium or premium taxes paid, just an administrative fee
- Exempt from most state regulations and mandates on coverage levels
- Stop Loss coverage available
- Maximizes cash flow
- Freedom to design your health benefits
- Financial protection against unanticipated, catastrophic claims
Health and Wellness Programs
Members of CIGNA HealthCare plans may also have access to valuable Health and Wellness programs and support.
- 24-hour health information — call the CIGNA HealthCare 24-Hour Health Information LineSM any time to speak with a registered nurse or listen to our audio library for health-related information.
- Support for chronic conditions — manage your asthma, diabetes, heart condition, low back pain, or chronic obstructive pulmonary disease with help from CIGNA Well Aware for Better Health®.
- Member discounts — save up to 60% on products and services-from acupuncture to weight management-with our Healthy Rewards® discount program. Note: not all programs are available in all states.
- Quality transplant care — access care from nationally recognized facilities in the CIGNA LIFESOURCE Transplant Network®.
- CIGNA HealthCare Healthy Babies® — give your child a healthy beginning with information and support from our Healthy Babies program.
- CIGNA Healthy Pregnancies, Healthy BabiesSM — the CIGNA Healthy Pregnancies, Healthy BabiesSM program offers a full scope of educational and care management services to members who are pregnant or considering pregnancy.
- Cancer prevention and education — the Comprehensive Oncology Program addresses cancer prevention and education, as well as active management of members diagnosed with cancer.
- High Touch Personal Assistance — with CIGNA Health AdvisorSM, CIGNA Health Advisors proactively identify and reach out to members who are at risk for significant health issues but are not appropriate candidates for chronic or acute disease or case management programs.
- Award Prgrams To Fit Your Needs — through the Healthy Awards Account® you can offer your employees health and well-being programs that are specific to your culture and needs.
- Lose weight and improve your health — when you enroll in the CIGNA Healthy Steps to Weight LossSM, you won't be starting a diet. Instead, this program helps you change your behaviors permanently. You'll learn healthier eating habits and how to incorporate exercise into your schedule – helping you to feel better, look better and improve your overall health.
Next (FAQ) >
FAQ
How do I find participating doctors?
Start with the CIGNA HealthCare Provider Directory or visit myCIGNA.
Do I need a referral to see a specialist?
Though you may want your doctor's advice and assistance in arranging care with a specialist in the network, you do not need a referral to see a participating specialist. Your plan does not cover services from specialists who do not participate in the CIGNA HealthCare network, except in emergencies.
What is utilization review?
Utilization review is a process that helps determine if the services you receive are a covered benefit. CIGNA HealthCare performs utilization review, including hospital pre-admission certification, continued stay review and case management. Requests for non-emergency hospital stays other than maternity stays must be approved in advance.
Precertification is not required for a maternity stay of 48 hours for vaginal deliveries or 96 hours for cesarean sections. Depending on your benefit plan, you may be eligible for additional benefits. Any hospital stay beyond the initial 48 or 96 hours must be approved. For details, please call the toll-free number on your CIGNA HealthCare ID card
What if my doctor keeps me hospitalized longer than my pre-admission certification allows?
CIGNA HealthCare will contact your hospital the day before your scheduled discharge. If you remain in the hospital beyond your original discharge date, CIGNA HealthCare will continue to review your hospital stay for coverage until you are discharged. If you remain in the hospital for services that are not covered, your costs may be higher.
Do I need precertification if my doctor recommends outpatient surgery for me instead of surgery with a hospital stay?
Some medical procedures are handled best in an outpatient setting. In most cases, you'll be home the same day, returning to your normal lifestyle as soon as possible. Certain outpatient surgical and diagnostic testing procedures must be pre-certified. Your benefits materials will provide you with information about precertification.
Who is responsible for obtaining pre-admission certification?
Your doctor will help you decide which procedures require hospital care and which can be handled on an outpatient basis. Your doctor will also arrange for precertification.
Am I covered for emergency care?
Whenever there is an emergency, seek medical help immediately. An emergency is an accident or sudden illness that a person with average knowledge of medical science believes needs to be treated right away or it could result in serious medical complications or permanent disability. Emergencies are covered 24 hours a day, seven days a week, no matter where you are.
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