This notice tells you about a change to your health plan beginning January 1, 2017.

Policy change

Beginning January 1, 2017, Cigna will apply the out-of-network benefit level to the services listed below unless there are special circumstances or prohibited by state law. If your plan does not cover out-of-network services, these claims may be denied. This means you may pay more out-of-pocket.

› Out-of-network assistant surgeons and surgical assistants at in-network facilities.  For example, if you receive services from an in-network surgeon at an in-network facility, but the assistant surgeon is out-of-network.

› Anesthesia services provided by an out-of-network health care provider as part of an in-network office visit.  For example, if you have a procedure in the doctor’s office and the anesthesiologist is out-of-network.

If your plan begins January 1, 2017, your new plan documents will show this change. If not, the change will be made to your plan documents at your next plan start date.

Remember, this policy change does not apply to out-of-network emergency, urgent care and emergency ambulance services.