YNHHS Medical Plan

The YNHHS Medical Plan connects you to the world-class care provided by our Signature Network of facilities and providers. You may also use Cigna Open Access Plus (OAP) or out-of-network providers, but you may pay more. It’s important to know that the organization has invested in our employees by keeping out-of-pocket costs—even for Cigna OAP services—lower than many of our health care industry peers.

When you enroll in the YNHHS Medical Plan, you automatically have prescription drug coverage.

The YNHHS Medical Plan is designed to help keep you and your family healthy. Used in tandem with your other benefits—including care and condition management and coaching services—it’s here to support you when you need care.

  • In most circumstances, you’ll pay nothing for preventive care—including some preventive tests and prescription drugs—when you use network providers.
  • If you choose a Signature Network provider, you’ll have copays and no annual deductible to meet. If you choose a Cigna Open Access Plus (OAP) or Out-of-Network provider, you will have to meet an annual deductible before receiving reimbursement for certain types of services.
  • Behavioral health and substance abuse benefits are included in the medical plan.
  • You only need to meet one combined annual out-of-pocket maximum for medical and prescription drugs. All your copays and coinsurance for covered services are applied toward this maximum. Once the out-of-pocket maximum is met, the plan pays 100% of eligible expenses for the remainder of the calendar year for each enrolled person.
  • Special rules apply when you or your covered dependents are covered by more than one plan.

You can choose to waive medical coverage if you’re covered by another plan or your spouse is a YNHHS employee. If you and your spouse are YNHHS employees, there is no need for each of you to have separate coverage under the YNHHS Medical Plan; one of you can enroll for YNHHS coverage and cover the other as a dependent.

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Understand the Networks

The amount you pay for care depends on whether you receive care from a Signature Network, Cigna Out-of-Area (OAP) or Out-of-Network provider. Click the links below to learn about the different types of providers and how it impacts what you pay for care.

Signature Network clinicians include:

  • Primary Care Physicians (PCPs) from Northeast Medical Group (NEMG), Yale Medicine (YM), Community Medical Group (CMG), WestMed, SoNE Health (Trinity Health of New England – CT only).
  • Specialists from NEMG, YM, CMG, SoNE Health and medical staff at a YNHHS hospital

View the YNHHS Medical Plan Tier 1 and Tier 2 Provider Listing.

Signature Network facilities include:

  • All YNHHS hospitals/locations, all PhysicianOne sites, and Trinity Health of New England facilities (CT only).
  • Fairfield Surgery Center, a division of OSG
  • Digestive Disease Associates – Branford Endoscopy Suite
  • WestMed Urgent Care and Immediate Care
  • OrthoFast (a division of OSG)

View the Trinity Health of New England facilities.

Search for a YNHHS facility that provides these services:

How the Signature Network Works

When you use a Signature Network provider or facility, you’ll pay less for most covered services. You pay a flat copay for care and do not have to pay a deductible before the plan begins to pay benefits. Once you meet your annual out-of-pocket maximum, the plan will pay 100% of covered expenses through that calendar year.
Note: Some Signature Network clinicians also provide care at facilities that are not part of our Signature Network. If you receive care at these other sites, you will pay higher costs for these facilities. For example, a surgeon who practices at Signature Network facilities may also perform surgery at private surgical centers. If your surgery is done at a private center, you would pay the Cigna OAP provider or Out-Of-Network provider rate for the doctor and the facility.

Patient Resource Coordinators

Patient Resource Coordinators are available to assist you with your Signature Network needs, such as:

  • Finding a physician,
  • Making an appointment,
  • Signing up for My Chart, and
  • Claims issues.

Call 844-543-2147, press option 3.

When you choose to receive care from a Cigna Open Access Plus (OAP) provider:

  • If you choose a provider in the Cigna OAP Network, you will have to meet your annual deductible before receiving reimbursement for certain types of services.
  • After you meet your deductible, you’ll generally pay 20% coinsurance or a copay until you reach your annual out-of-pocket maximum.
  • Once you meet your annual out-of-pocket maximum, the plan will pay 100% of covered expenses through that calendar year.

To find a provider in the Cigna OAP Network, visit myCigna.com or call 833-739-6447 (833-73-YNHHS). Or download the myCigna app to find health care services, resources, and important contacts.

When you use a provider or facility that is not in the Signature or Cigna OAP network:

  • You’ll pay the most for care.
  • Cigna will pay a maximum reimbursable charge (MRC) for covered services.
  • You will be responsible for costs up to your annual deductible, coinsurance, and any difference between the MAA and the amount billed by the provider.
  • You’ll need to file a claim for the care to be covered. Payments will be made directly to the provider unless you submit a bill showing you’ve paid it already. Get a claim form and instructions.

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Get no-cost vaccines when you use the right ID card

You and your covered dependents can get no-cost vaccines for shingles, pneumonia, flu (ages 18 and older only), COVID-19, tetanus/diphtheria, and hepatitis A and B. To ensure 100% coverage, show the right ID card. If you are in a CVS Minute Clinic or Health Hub, use your medical plan ID card. Any other network pharmacy, use your CVS Caremark ID card.

Find a network pharmacy

How Benefits Compare Based on the Provider You Choose

Here’s a look at how the benefits compare based on whether you receive care from a Signature Network, Cigna OAP Plus or Out-of-Network provider. For a more complete list and any limitations, visit HRConnect to view the summary plan description (SPD). To see employee premium contributions for the medical plan, visit the enrollment site.

 Signature Network  Facility/ProviderCigna Open Access Plus (OAP) Provider Out-of-Network Provider 

Annual Deductible
(individual/family)

$0/$0 $1,750/ $3,500 $10,000/$20,000 

Out-of-Pocket Maximum1
(individual/family)

$3,000/6,000 $8,150/$16,300 (combined with prescription drugs)$30,000/$60,000 

1. Amounts you pay toward care provided by all in-network providers accumulate toward both the YNHHS and Cigna Open Access Plus (OAP) out-of-pocket maximums. However, when the YNHHS in-network out-of-pocket maximum has been reached, amounts paid for YNHHS in-network care no longer accrue toward the Cigna OAP out-of-pocket maximum. Amounts paid for Cigna OAP in-network care continue to accrue until the Cigna OAP out-of-pocket maximum is met.

 Signature Network Facility/Provider Cigna Open Access Plus (OAP) Provider Out-of-Network Provider 

Primary Care Visit
(in-person or electronic)1,2

$20 copay   $40 copay  50% of MRC* after deductible7

Specialist Office Visit
(in-person or electronic)1

$35 copay$60 copay  50% of MRC* after deductible7

Routine Adult 1,3

0%, no copay

0%, no copay

50% of MRC* after deductible7

Doctor or Surgeon Services4

0%, $0 copay  

20% after deductible6

50% of MRC* after deductible7

Allergy Shot in Doctor's Office
(no MD visit)

$20 copay  $40 copay  50% of MRC* after deductible7

Nutrition Counseling and Diabetes Self-Management Training 5

0%, no copay  0%, $0 copay  50% of MRC* after deductible7

*Maximum reimbursable charge
1. Tests (e.g., some lab work) that are associated with office visits may be subject to a copay or deductible and coinsurance if they are not mandated by the Affordable Care Act (ACA). Check with your provider or call Cigna to determine if a specific test is covered at 100%. In addition, some Signature Network providers send lab work to a Cigna OAP lab. In this case, the lab work is covered as a Tier 2 benefit.
2. Find a list of Signature Network providers.
3. One exam every calendar year starting at age 22 (includes immunizations).
4. Other than office visit; includes maternity claims.
5. Nutritional counseling is covered with no limit for mental health/substance abuse (anorexia or bulimia) and diabetes (that are medically necessary). For all other conditions, there is a 3-visit maximum per calendar year. Note: The YNNHS livingwellCARES program also provides nutritional counseling services at no cost to the member.

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* Maximum reimbursable charge
1. One per calendar year. All other OB/GYN office visits are covered at the specialist office visit benefit level.
2. Screening (preventive/routine) mammogram only. Does not include breast ultrasounds.
3. Prenatal care and delivery. Well visits to the obstetric provider are billed with one global fee that includes trimester visits, delivery, and postpartum care. Any maternity-related tests that are needed, such as blood work, glucose tolerance tests, stress tests, ultrasounds, or amniocentesis, are billed separately. Inpatient hospital and doctor or surgeon services also apply.
4. Seven exams from birth to age 1 year; seven exams from ages 1 to 5; one exam from ages 6 to 21.
5. Tests (e.g., some lab work) that are associated with office visits may be subject to a copay or deductible and coinsurance if they are not mandated by the Affordable Care Act (ACA). Check with your provider or call Cigna to determine if a specific test is covered at 100%.
6. The Signature Network Facility/Provider is Yale Reproductive Endocrinology and Infertility (REI) Center, which has locations in Greenwich, Fairfield, New Haven and New London. Prescription medications are also included up to a lifetime maximum of $2,000 through your CVS Caremark pharmacy benefit. However, specialty medications need to be obtained through YNHHS Outpatient Pharmacy Services.

TABLE

* Maximum reimbursable charge
1. Includes x-rays, echo stress tests, ultrasounds, diagnostic mammograms, sleep studies, and EKGs. Patients will receive a bill for the reading of the diagnostic testing and imaging (covered under “Doctor or Surgeon Services”).
2. PET, SPECT, MRI, MRA, CTA, and CAT.
3. Diagnostic colonoscopies covered under the outpatient surgery benefit level. Includes fecal occult blood test, barium enema, flexible sigmoidoscopy, and screening colonoscopy.
4. Chiropractic, physical therapy, occupational therapy, and speech therapy combined maximum: 50 visits per calendar year. Maintenance therapy is not covered under chiropractic care and medical necessity will be reviewed after the fifth visit.
5. Cardiac rehabilitation: maximum 36 visits per calendar year.

TABLE

* Maximum reimbursable charge
1. Room and board, lab work, medical supplies, and other hospital ancillary services.
2. Hospital or surgical center facility charges only.
3. Some Tier 1 providers send lab work to a Tier 2 lab. In this case, the lab work is covered as a Tier 2 benefit.

TABLE

* Maximum reimbursable charge
1. The Employee and Family Resources (EFR) program provides up to six confidential counseling sessions at no cost.
2. Includes ABA therapy, Intense Outpatient Program (IOP) and Partial Hospitalization Program (PHP).

TABLE

* Maximum reimbursable charge

TABLE

* Maximum reimbursable charge
1. Up to 120 days per calendar year after a hospital stay. Combined for skilled nursing and home health care.
2. Up to 120 days per calendar year. Combined for skilled nursing and home health care.
3. No day limit.

TABLE

* Maximum reimbursable charge
1. Two hearing aids every 36 months.

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Examples of How Costs Can Be Impacted by the Network You Choose

These examples* show how using a Signature Network provider and/or facility can impact your out-of-pocket costs. As a reminder, if you use a Signature provider but your care takes place in a facility that is not in our network, the facility expenses will be covered as Cigna or out-of-network care.

Tony saves $5,750 using a Signature provider and Signature facility for his inpatient hip surgery.

TABLE

If Tony had the same procedure, but it takes place in a Cigna facility, he will spend $5,150 more than in the first example.

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* These examples are for illustrative purposes only. Your actual cost share may vary depending on the care you receive, the facility used, and specifics if you’re admitted as an inpatient. These examples are not provided as a guarantee of coverage or an actual estimate of specific benefits under the plan.

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When to Connect with Cigna

For a medical, behavioral health, or substance abuse stays and/or service pre-authorizations, call 833-739-6447 (833-73-YNHHS).

Before receiving any of these services, you must call Cigna for preauthorization.

Otherwise, your benefits will be reduced.

  • Inpatient stays in a hospital, skilled nursing facility, hospice facility, subacute care or acute rehabilitation facility, or a behavioral health or substance abuse treatment center. (Call at least 24 hours before the start of your stay).
  • High-cost diagnostic imaging services prescribed by an out-of-network provider.
  • Organ/tissue transplants, including evaluation, donor search, organ procurement/tissue harvest, or transplant.

For admissions following emergency or urgent care, you, your representative, or your doctor must call Cigna within 48 hours of admission.

  • Benefits for inpatient stays will be reduced by $200.
  • Benefits for doctor fees will be reduced by 25%.

  • Find a provider in the Cigna Open Access Plus (OAP) Network.
  • Resolve insurance claim and billing issues.
  • Ask questions about preventive and/or diagnostic care.
  • Get general health information.

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No ID Cards Needed

No ID cards are needed when you receive care under the YNHHS Medical Plan. Your provider will be able to access all your information through their system when you tell them you’re covered under Cigna. If you want an ID card, you can simply download one from the Cigna app, which you can download from the App Store or Google Play.

Urgent Care & Telehealth

Can’t wait to see a doctor? Urgent care and telehealth services help you quickly connect with affordable care.

Urgent Care

When you need immediate care for an illness or injury, you may have options for both Signature Network and Cigna OAP. To locate an urgent care center close to you, visit myCigna.com and search for urgent care. You’ll pay a $35 copay when visiting a Signature Network facility. You’ll pay more if you use other providers.

Telehealth

Telehealth is an ideal alternative for immediate treatment of an illness or injury when you can’t get to a doctor’s office or urgent care center. You and your covered family members can visit a doctor virtually, wherever you are, whenever you need care—via phone, tablet or computer. If you need medication, the doctor can even send a prescription to your pharmacy (within Connecticut, New York, Massachusetts and Rhode Island).

Use OnDemand or MDLIVE to connect to care outside the usual office hours. Telehealth is not an alternative to emergency care for a life-threatening condition.

See one of our own Northeast Medical Group (NEMG) providers weekdays from 7 a.m. to 7 p.m. ET, excluding holidays. To get started, download the MyChart mobile app.

The NEMG providers you see OnDemand can:

  • Diagnose symptoms
  • Order testing
  • Prescribe medication
  • Send prescriptions to the pharmacy of your choice in Connecticut, New York, Massachusetts, and Rhode Island

OnDemand does not cover pediatric services. Find more information about OnDemand at HRConnect.

How OnDemand works

  1. Register with MyChart online at ynhhs.org/ondemand or through the mobile app.
  2. Schedule your OnDemand visit. You’ll get reminder emails, phone calls, and app pushes to remind you of your upcoming visit.
  3. Complete e-Checkin on the mobile app or website 15 minutes before your visit. You’ll answer questions about your medical history and insurance coverage.
  4. Pay for your visit with a credit card, debit card or your HSA Bank Flexible Spending Account debit card.
  5. Join a virtual waiting room, where a medical assistant will greet you and confirm your information.
  6. Visit your OnDemand doctor.
  7. After your appointment, find a summary of your visit in the MyChart app.

When you or your child can’t wait for care MDLIVE is there for you 24/7/365.

Pediatric services are not covered by OnDemand. Call 888-MDCARE-8 or 888-632-2738.

For pediatric services, or to see a board-certified doctor after hours, on weekends and holidays, and when you’re out-of-state, visit MDLIVE online, download the mobile app or call 888-MDCARE-8 or 888-632-2738.

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Prescription Drugs

You automatically have prescription drug coverage when you enroll in the YNHHS Medical Plan. You can fill covered prescriptions at participating CVS retail pharmacies, through mail order or through YNHHS Outpatient Pharmacy Services.

Your prescription will be covered only if it’s filled at a participating pharmacy. To fill a:

  • 30-day supply prescriptions, just present your prescription and CVS Caremark prescription drug card at a pharmacy in the CVS Caremark network.
  • Maintenance medication, you must use a CVS retail pharmacy, mail order, or visit a YNHH Specialty Pharmacy. With CVS Maintenance Choice, you get up to two 30-day fills at a retail pharmacy before you’ll need to use mail order, CVS pharmacy or a YNHH Specialty Pharmacy for 90-day fills.
  • For specialty medications, you’ll need to use mail order or specialty pharmacy services, as described in the chart below.

In an emergency or if you’re out of state and can’t get to a participating pharmacy, you’ll pay out of pocket and then file a claim for reimbursement from CVS Caremark. When you’re covered by the YNHHS Medical Plan, the out-of-pocket maximum is the most you’ll pay out of pocket for medical care and prescription drugs.

Note: When a generic is available and you or your doctor chooses a brand-name drug, you’ll pay the brand-name coinsurance—plus the difference in cost between the two medications.

For medications you take on an ongoing basis, you’ll use the CVS Caremark Maintenance Choice program to get refills at a lower copay for a larger supply. With CVS Maintenance Choice, you get up to two 30-day fills at a retail pharmacy before you’ll need to use CVS Caremark mail service or a CVS Pharmacy for 90-day fills.

What you’ll pay depends on the type of drug and the amount prescribed. When the cost of a drug is less than the minimum copay, you’ll pay the lower amount.

You only need to meet one combined annual out-of-pocket maximum for medical and prescription drugs. All your copays and coinsurance for covered services are applied toward this maximum. Once the out-of-pocket maximum is met, the plan pays 100% of eligible expenses for the remainder of the calendar year for each enrolled person.

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If you or your covered dependents are enrolled in the YNHHS Medical Plan and take specialty medications, you can access a free program that will save you money by reducing out-of-pocket costs for eligible specialty medications. CVS Caremark, YNHHS’ prescription drug plan administrator, has partnered with PrudentRx to offer this program for eligible specialty medications. If your specialty medication is on the PrudentRx Exclusive Specialty Drug List, you will have a $0 copay for your medication(s). If your medication is on the Prudent Rx Specialty Drug List, and you do not enroll in their program, you will pay 30% of the medication cost.

To receive this benefit, specialty medications must be filled through the YNHH Specialty Pharmacy Services at 844-881-0043, the Apothecary & Wellness Center at 203-789-4076 or YNHH Pharmacy at North Haven Medical Center at 203-230-3940.

To take advantage of this program or to see if your specialty medication is on the PrudentRx drug list, call PrudentRx at 800-578-4403, Monday through Friday, 8 a.m. – 8 p.m. Eligible employees must register first with PrudentRx before filling a prescription.

Preauthorization and Other Special Circumstances

Here are some drugs where preauthorization will be required and there may be other special circumstances to be aware of.

Some prescriptions, including compounded drugs, require preauthorization from CVS Caremark before they can be filled. Your pharmacist will let you know if your doctor needs to make that call.

If you’re taking raloxifene (brand name: Evista) or tamoxifen (brand name: Noladex) for primary prevention of breast cancer, these generics may be available at no cost to you through the preventive provisions of the Affordable Care Act. To learn if you qualify, your doctor will need to complete the Preventive Services Zero Cost Sharing Form and fax it to CVS Caremark.

The step therapy program requires you to try one or two generic equivalents before the brand-name drug will be covered.

Drug classes included in this program include medications that treat high cholesterol, high blood pressure, gastrointestinal disorders (GERD, for instance), sleep disorders, depression, and other conditions.

The following drugs and medical supplies are not covered by the plan:

  • Medical devices and appliances
  • Experimental drugs
  • Drugs whose sole purpose is to promote or stimulate hair growth
  • Retin A (for those over age 28)
  • Weight-loss drugs
  • Immunization agents, biological sera, blood or blood plasma
  • Most over-the-counter drugs, vitamins, and nutritional supplements
  • Ostomy supplies
  • Prescription ophthalmic products used to improve the field of vision (e.g., presbyopia, blepharoptosis, drug-eluting contact lenses, etc.)
  • Certain drugs that have limited clinical value and which have clinically-appropriate, lower-cost alternatives (e.g., brand name or generic drugs that are combinations of existing generic or over-the counter drugs, new formulations of existing drugs)

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Need to fill a prescription?

Find a participating pharmacy near you.

Connect with a local pharmacy

Pay Nothing for Certain Preventive Drugs

The Affordable Care Act (ACA) makes many prescription medications, vaccines, and supplements—including contraceptives and statins—available to you at no cost.

No-Cost Preventive Drug List

No ID Cards Needed

No ID cards are needed when you fill a prescription under the YNHHS Medical Plan. Your pharmacy will be able to access all your information through their system when you tell them you’re covered under CVS. If you want an ID card, you can simply download one from the CVS app, which you can download from the App Store or Google Play.

Ready to Enroll?

Learn about your YNHHS benefits by visiting our virtual benefits fair. Then, to enroll or make changes to your benefits, visit bswift, our secure, online enrollment website. You’ll be prompted to enter your YNHHS username and password. If you are enrolling before your hire date, use this link to visit bswift and follow the temporary username and password instructions there. If you run into problems, call HRConnect at 844-543-2147. Need more info first? You’ll find details at HRConnect.

Visit Virtual Benefits Fair
Visit bswift