893368 THN-2016-474 09/16

Cigna SureFitTM is a new plan offering that builds networks around local physician and hospital groups and provides our customers with access to personal, patient-centered care. Patients get to choose the primary care physician (PCP) that works best for their individual needs. And they can receive all of their care within the community of care network.

CIGNA SUREFIT

Denver and Boulder, Colorado

Important plan information

Hospital networkBoulder Community Hospital (BCH), HealthONE, Sisters of Charity of Leavenworth (SCL)

Emergencies In-network and out-of-network coverage for emergency care*

PCP selection PCP selection is required

Specialist referralsReferrals required. Select from health care professionals participating in the network aligned to the Cigna SureFit plan

Out-of-network coverage Visits to providers outside of the network aligned to the Cigna SureFit plan are not covered

National ancillary providersAll Cigna-contracted national ancillary providers currently in the market participate

Participating health care professionals search

Access the online directory at Cigna.com/hcpdirectory/

*For emergency medical conditions as defined in the plan documents.

Look in the top right corner of the ID card to identify the network aligned to the patient’s plan

Images for illustrative purposes only.

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•PresentthisID

cardeach

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visitahealthcare

professional.•

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questionsortoelectorchangeyourPCP,please

visitourwebsite

orcallthetoll-free

customerservicenumberlocated

onyourID

card.

Group: 00699999Issuer (80840)ID: 911111102Name: Christianna Q Johnson-SmythePCP: Bartholomew Johannsen MD

GCigna Health and Life Insurance Comapny

Referral RequiredSureFit CO FI

RxBIN 017010 RxPCN 05180000RxGrp 00699999 RxID 911111102 00

ABCDEFGHIJKLMNOPQRSTUVWXYZabcdefghijkl 123456789012345678921234567893123456

Primary CareSpecialistUrgent CareERHospital Stay

$25/0%$50/0%$50/10%$150/10%$500/20%

030409440935

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Mask 703 Issue Date: 11/25/15

*116*

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Christianna Johnson-Smythe124 Purple PlaceDenver, CO 80999

20151125Wed Nov 25, 2015 @ 16:48:22N

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Total Cigna DPPO

CO-DOI

You may have to show this card when you receive care. This doesn’t guarantee coverage. Not using this card correctly is fraud. For emergencies, call 911 or get immediate care. Contact your 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. Health Care Professionals: Check your provider contract for precertification requirements. Customers: myCigna.com Health Care Professionals: CignaforHCP.com

Boulder and Denver, CO

Cigna SureFit service area for Boulder and Denver, Colorado

Adams, Arapahoe, Broomfield, Boulder, Denver, Douglas, and Jefferson counties

The network aligned to the Cigna SureFit plan includes access to many hospital and physician groups, including:

Hospital systems

› Boulder Community Hospital (BCH)

› HCA/HealthONE

› Sisters of Charity of Leavenworth (SCL) (formerly Exempla)

Cigna Collaborative Care (CCC) large physician groups

› Community Medical Associates

› New West Physicians

› PHPprime

› Rose Integrated Health Network

This listing is not all inclusive. For a complete listing of physicians and facilities, please refer to the online health care professional directory at Cigna.com/hcpdirectory/.

Cigna SureFit service areaHHospital locations

● Physician groups

JEFFERSONARAPAHOE

DOUGLAS

ADAMSBROOMFIELD

BOULDER

HH

HHHH

H

H

H

H

DENVER

Referrals and precertification

To support coordination of care, PCPs must request referrals to specialists for their patients with a Cigna SureFit plan. Precertification may be required for some services.

If you need to submit a referral or obtain precertification for a patient, please use one of the following options.

› Health care request and response (ANSI 278): Contact your electronic data interchange (EDI) or practice management system vendor.

› Phone: 1.866.494.2111, choose the prompt for specialist referral or precertification.

› Fax: 1.866.873.8279. You can obtain referral and precertification forms on the Cigna for Health Care Professionals website (CignaforHCP.com > Resources > Form Center > Medical Forms).

› Mail: Cigna Attn: Precertification and Referral Department 2nd Floor, 1640 Dallas Parkway, Plano, Texas 75093

Specialists can confirm referrals by using one of the following options.

› The PCP’s written referral presented by the patient

› Calling Cigna Customer Service at 1.866.494.2111. Choose the prompt for specialist referral

When making referrals, access the online directory at

Cigna.com/hcpdirectory/ to find participating physicians, hospitals, and other health care professionals.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, and Cigna Behavioral Health, Inc. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. All pictures are used for illustrative purposes only.

893368 THN-2016-474 09/16 © 2016 Cigna. Some content provided under license.

Questions? We’re here to help. Visit CignaforHCP.com or call 1.866.494.2111.

To avoid delays in processing your referral or precertification, please confirm your EDI vendor is using “SC” for specialty care review in the Request Category Code field (UM01 segment) for referrals, and “AR” for admission review or “HS” for health services review in the Request Category Code field (UM01 segment) for precertification.