Transition of Care & Continuity of Care Request Form

This document explains how to request temporary in-network benefits when continuing treatment with an out-of-network doctor, and it includes the application form required to apply. It outlines rules, eligible medical conditions, and application submission instructions:

• Transition of Care: Provides temporary in-network coverage levels for new plan members who are already undergoing active treatment for specific conditions with an out-of-network doctor. You must apply within 30 days of your coverage effective date.

• Continuity of Care: Provides temporary in-network coverage levels when your current doctor leaves the Cigna network while you are actively receiving treatment. You must apply within 30 days of your doctor's network termination date.

• Qualifying Conditions: Covers acute, ongoing treatment such as high-risk pregnancy, active cancer care (chemotherapy/radiation), recent major surgery follow-ups (6–8 weeks), transplants, or active behavioral health treatment. Stable chronic conditions, routine check-ups, minor illnesses, and elective surgeries do not qualify.

• Form & Filing Instructions: Includes the detachable request form, requiring details about the patient, medical condition, and attending doctor. Completed forms must be signed and submitted by mail or fax to Cigna Healthcare (or Evernorth for behavioral health) for review.