The Cigna Benefits Compass: An Expert Analysis of Offerings, Realities, and Member Strategy

Introduction: The Cigna Paradox – A Universe of Benefits, A Labyrinth of Realities

Cigna presents itself as a comprehensive partner in its members’ well-being, on a mission to improve their “health, wellbeing and peace of mind”.¹

The company’s public-facing image is that of a modern, digital-first insurer offering a vast portfolio of plans, personalized support programs, 24/7 virtual care, and robust wellness incentives.²

This report, however, explores the fundamental disconnect between this advertised ideal and the documented reality of a complex, often adversarial system that members must navigate.

The analysis will deconstruct Cigna’s offerings not merely through its marketing materials but through the critical lens of extensive user-reported data and official documentation.

This investigation reveals two distinct versions of the company.

The first is Cigna-as-Advertised, a sophisticated organization providing a wide array of medical, dental, vision, and behavioral health products designed for every stage of life.²

The second is Cigna-as-Experienced, a bureaucratic entity that, according to a significant volume of member feedback, is characterized by systemic claim denials, frustrating processing errors, unresponsive customer service, and a structure that appears engineered to create friction for those seeking care.⁶

The goal of this report is to provide a comprehensive, evidence-based guide that empowers current and prospective members to understand the full Cigna ecosystem.

It aims to equip them to anticipate common challenges and develop effective strategies for self-advocacy in a system where such skills are not just beneficial, but essential.

A crucial observation underpins this analysis: Cigna’s operating subsidiaries maintain strong financial strength and credit ratings, including an “A” from both Standard & Poor’s and A.M. Best ¹⁰, while the company’s customer-facing entities garner exceptionally poor user satisfaction scores, such as a 1.05 out of 5 average on the Better Business Bureau.¹¹

A financially successful corporation does not “accidentally” sustain such a high volume of negative customer experiences over many years.

The persistence of these issues suggests they may not be a flaw in the system, but rather a feature of its operational model.

User complaints consistently center on difficulties getting care paid for, including claim denials, pre-authorization hurdles, reimbursement errors, and an unhelpful appeals process.⁶

Each of these obstacles requires significant effort from the member to overcome.

A certain percentage of members will inevitably abandon their efforts at each stage, forgoing a reimbursement or a covered procedure.

This abandonment translates directly into lower payouts for Cigna, thereby enhancing profitability.

This dynamic suggests that the friction within the system may be a financially rational, albeit member-hostile, strategy.

Consequently, this report treats member challenges not as isolated incidents but as predictable outcomes of a system that appears optimized for cost containment.

This reframes the member’s role from that of a passive “customer” to an active “advocate” who must anticipate and navigate these systemic hurdles.

Part I: Deconstructing the Cigna Benefits Portfolio

This section provides an objective detailing of the products Cigna offers, serving as a foundational encyclopedia of their benefits ecosystem.

Chapter 1: Core Medical Coverage – Navigating the Alphabet Soup (HMO, PPO, EPO)

Cigna’s core offerings consist of several types of health plans, available both through employers and on the individual marketplace, each defined by a different balance of cost, choice, and flexibility.⁴

Understanding these fundamental structures is the first step for any member.

Health Maintenance Organization (HMO): The Walled Garden

An HMO plan operates within a local, limited network of doctors and hospitals.

This structure is designed to control costs, generally resulting in lower monthly premiums and out-of-pocket expenses for members.¹⁶

A key feature of most HMOs is the requirement to select a Primary Care Physician (PCP) who acts as a gatekeeper, coordinating all care and providing referrals for any necessary specialist visits.¹⁶

The critical limitation of an HMO is its rigid network boundary; there is typically no coverage for care received from out-of-network providers, with the sole exception of true medical emergencies.¹⁶

Preferred Provider Organization (PPO): The Flexible (but Pricier) Option

In contrast to the HMO, a PPO plan offers significantly more flexibility.

It features a larger network of participating providers and allows members to seek care from out-of-network doctors and hospitals.¹⁶

This freedom comes at a cost, as PPOs typically have higher monthly premiums.

Furthermore, when members go out-of-network, they face higher cost-sharing and must often meet a separate, higher deductible.¹⁹

A major advantage of the PPO model is that it does not require members to have a PCP or obtain referrals to see specialists, offering direct access to a wider range of care.¹⁶

Exclusive Provider Organization (EPO): The Hybrid Model

The EPO model blends features of both the HMO and PPO.

It utilizes a local network of providers that is generally larger than an HMO’s but smaller than a PPO’s.¹⁶

Like a PPO, an EPO plan typically does not require a PCP or referrals for specialists.¹⁶

However, its cost structure is more akin to an HMO.

Premiums are usually lower than a PPO’s, but the plan offers no coverage for out-of-network care, except in emergencies.¹⁶

This makes the EPO a potential pitfall for members who do not verify the network status of every provider.

Marketplace Plans (ACA)

For individuals purchasing their own insurance on the Affordable Care Act (ACA) marketplace, Cigna offers plans across the Bronze, Silver, and Gold metallic tiers.

These tiers are differentiated by how costs are shared between the member and the plan, with Bronze plans having lower premiums and higher out-of-pocket costs, and Gold plans having the reverse.¹⁴

A 2024 Forbes Advisor review noted that Cigna’s Silver plans, the most popular marketplace option, tend to have lower-than-average deductibles but higher-than-average monthly premiums.²¹

Plan Feature	Health Maintenance Organization (HMO)	Preferred Provider Organization (PPO)	Exclusive Provider Organization (EPO)
Monthly Premium	Lowest 16	Highest 16	Medium 16
PCP Required	Typically Yes 17	No 18	Varies by plan, often No 16
Referrals Needed	Typically Yes 17	No 18	No 16
In-Network Coverage	Covered according to plan terms	Covered at the lowest cost-sharing	Covered according to plan terms
Out-of-Network Coverage	None, except for emergencies 16	Yes, but at a higher cost 19	None, except for emergencies 16
Network Size	Local, more limited 16	Large, national 15	Local, larger than HMO 16
Best For	Members prioritizing low premiums who are comfortable with a limited network and PCP gatekeeper.	Members prioritizing flexibility and direct access to specialists who are willing to pay higher premiums.	Members seeking a balance of lower premiums and direct specialist access who can strictly remain in-network.

Chapter 2: Beyond Medical – A Deep Dive into Dental, Vision, and Supplemental Plans

Cigna’s portfolio extends well beyond standard medical insurance, offering a suite of products designed to provide more holistic coverage.

Dental Plans: The DHMO vs. DPPO Divide

Similar to its medical plans, Cigna’s dental offerings are primarily split between two models: the Dental HMO (DHMO) and the Dental PPO (DPPO).²²

• DHMO plans are built for cost-effectiveness. They typically feature no annual deductible and no annual benefit maximum, meaning members do not “run out” of coverage.²² However, they require the member to select a primary care dentist from a limited network and obtain referrals for specialists. There is no coverage for out-of-network care.²³
• DPPO plans offer greater flexibility. Members can see any licensed dentist, though they save money by staying in-network.²⁵ These plans do not require a primary dentist or referrals. This flexibility comes with higher costs, including an annual deductible, coinsurance, and a yearly maximum on benefits paid by the plan.²²

Plan Feature	Dental HMO (DHMO)	Dental PPO (DPPO)
Annual Deductible	No 24	Yes 24
Annual Maximum	No 22	Yes 22
Primary Dentist Required	Yes 24	No 24
Referrals to Specialists	Yes 23	No 22
Out-of-Network Coverage	No (except emergencies) 23	Yes (at higher cost) 25

Vision Coverage: An Integrated Add-On

Cigna’s vision benefits are typically not sold as standalone policies but are offered as an enhancement to a medical or dental plan.²⁶

This coverage is intended for routine eye care, such as annual exams, eyeglasses, and contact lenses.

It is important to note that medical issues affecting the eyes, such as glaucoma, cataracts, or eye injuries, are covered under the member’s core medical plan, not the vision add-on.²⁶

Cigna also offers bundled plans, such as the “Cigna Dental Vision Hearing 3500,” which provide specific dollar allowances for services like vision exams and eyewear.²⁷

A critical structural detail is that Cigna “delegates the contracting of routine vision services to EyeMed”.²⁶

This means that while a member pays premiums to Cigna, their vision network and service experience are managed by a separate company.

This creates a potential “seam” in customer service, where a Cigna representative may be unable to resolve a vision-related issue, forcing the member into the kind of frustrating, circular conversations described in numerous complaints.⁶

The member may believe they are dealing with one company, when in fact their care is fragmented across multiple operational entities.

Supplemental Insurance: Filling the Gaps

Cigna offers a range of supplemental insurance policies designed to provide financial protection against specific health events.

These plans pay cash benefits directly to the member for occurrences like a heart attack, stroke, cancer diagnosis, or hospitalization.²

These are not comprehensive health plans but are intended to help cover deductibles, copayments, and other non-medical costs that arise during a major health crisis.

Medicare Plans

For the senior population, Cigna provides a full suite of Medicare products.

This includes Medicare Advantage (Part C) plans, which are private plans that replace Original Medicare; Medicare Supplement Insurance (Medigap) policies, which help cover the costs left over by Original Medicare; and standalone Medicare Part D Prescription Drug Plans.²

Chapter 3: The Modern Perks – An Analysis of Wellness and Behavioral Health Programs

Cigna heavily markets a suite of modern benefits focused on proactive health management and mental well-being, positioning itself as a holistic health partner.

The Wellness Ecosystem

Cigna has developed several programs to encourage healthy behaviors through financial incentives and discounts.

• Incentive Programs: The “Cigna Take Control Rewards®” program is a prominent feature for individual and family plan members. It allows subscribers to earn points for completing healthy actions, such as getting an annual wellness exam. These points can be redeemed for a reloadable debit card that can be used for healthcare costs.³ A separate “Healthy Rewards® Program” provides members with discounts on a wide range of products and services, including gym memberships, fitness apps, vision care, and meal delivery services.³
• Lifestyle Management: For members looking to make specific health improvements, Cigna provides lifestyle management programs with online or phone-based coaching for stress reduction, weight management, and tobacco cessation.²⁹

The Behavioral Health Ecosystem: A Critical Lifeline

Recognizing the importance of mental health, Cigna has built an extensive behavioral health offering.

• Coverage: Mental health and substance use benefits are typically integrated into a member’s medical plan, meaning there is no separate deductible to meet.³⁰ Plans generally cover therapy for common conditions such as anxiety, depression, and mood disorders.³¹
• The Provider Network: A key strength of Cigna’s offering is its large national network of behavioral health providers. This is augmented by what it calls one of the largest virtual behavioral networks, accessible through third-party partners like MDLIVE®, Talkspace, and Ginger.³² This digital infrastructure provides members with 24/7 access to licensed therapists and psychiatrists, often with a $0 copay for virtual visits.⁴
• Employee Assistance Program (EAP): Often provided through employers, the EAP is a confidential benefit that gives employees and their household members access to support for personal issues, which frequently includes a set number of free counseling sessions per issue, per year.¹³

This impressive ecosystem of partners, however, introduces the same structural risk seen in vision benefits.

Behavioral health services are administered by a Cigna subsidiary, “Evernorth Behavioral Health, Inc.” ³⁰, while virtual care is delivered by a host of third-party companies.³³

This fragmentation can lead to significant service gaps.

For instance, one user complaint specifically identifies Evernorth as being “a pain to get a hold of”.⁶

Another member lamented that Cigna uses third parties for processing and then has “no way of reaching their third party processors” to resolve errors.¹²

This means a member seeking urgent mental health support might be directed by Cigna to a partner, but if a problem with billing or scheduling arises with that partner, Cigna’s own customer service may be powerless to intervene.

The “seamless” integration promised in marketing materials does not always reflect the operational reality.

Part II: The Member’s Gauntlet – A Practical Guide to Using Your Cigna Plan

This section shifts from analyzing what Cigna offers to the documented reality of using the plan, integrating widespread user-reported experiences to create a practical guide.

Chapter 4: The Financial Engine Room – Mastering Deductibles, Copays, and Coinsurance

Understanding the financial mechanics of a Cigna plan is paramount to managing healthcare costs and avoiding surprises.

The three key cost-sharing mechanisms are deductibles, copayments, and coinsurance.

• Deductible: This is the fixed amount of money a member must pay out-of-pocket for covered medical services each year before the insurance plan begins to pay its share. Deductible amounts vary significantly between plans, and PPO plans often have separate, higher deductibles for in-network versus out-of-network care.³⁴
• Copayment (Copay): This is a fixed fee paid by the member at the time of service, such as a $25 fee for a PCP visit or a $50 fee for a specialist.³⁷ Copayments typically do not count toward the annual deductible, but they do contribute to the out-of-pocket maximum.³⁷
• Coinsurance: This is the percentage of costs a member shares with the insurance plan after the annual deductible has been met. For example, in a plan with 20% coinsurance, the member pays 20% of the allowed cost of a service, and Cigna pays the remaining 80%.³⁶

A common point of confusion for families is the structure of their deductible.

Cigna plans can have a single, aggregate family deductible, where all members’ costs contribute to one shared amount.

Alternatively, a plan can have an “embedded” individual deductible, where each family member has their own deductible to meet within the larger family deductible framework.³⁹

Knowing which type of deductible a plan has is critical for accurately predicting family healthcare expenses.

Finally, all plans have an out-of-pocket maximum.

This is the absolute most a member will pay for covered in-network services in a plan year, including money spent on deductibles, copays, and coinsurance.

Once this limit is reached, the plan pays 100% of the costs for covered services for the remainder of the year.³⁹

Chapter 5: Your Digital Lifeline? A Critical Review of the myCigna Portal and EOBs

Cigna positions its digital tools, particularly the myCigna portal and the Explanation of Benefits (EOB), as central to the member experience.

The myCigna Portal and App

Cigna heavily promotes the myCigna online portal and mobile app as a one-stop shop for managing all aspects of a health plan.

The advertised features include finding in-network doctors, checking the status of claims, viewing and sharing digital ID cards, managing health spending accounts like HSAs, and accessing wellness programs.²⁸

Registration is required and involves providing personal information to verify identity.⁴³

However, there is a stark contradiction between these promises and the user experience.

Multiple members report that the website is “glitchy, confusing, and often doesn’t work properly,” transforming a tool meant for convenience into a source of frustration.⁹

Deciphering the Explanation of Benefits (EOB): Your Most Important Document

The single most important document for a Cigna member to understand is the Explanation of Benefits (EOB).

Crucially, an EOB is not a bill.

It is a statement generated after a provider submits a claim, and it details how that claim was processed.

It shows the provider’s original charge, any network discounts applied, the amount Cigna paid, and the amount the member may be responsible for paying.⁴⁴

A line-by-line understanding of the EOB is essential for self-advocacy.

EOB Term	Plain English Meaning	What to Look For (Potential Errors)
Amount Billed	The provider’s full, non-discounted charge for the service.46	Does this match the services you actually received? Check for duplicate charges or services you did not get.
Allowed Charges / Discount	The negotiated rate Cigna pays for that service with an in-network provider. The discount is the difference between the Amount Billed and the Allowed Charges.47	If you saw an in-network provider, there should be a discount listed. If not, the provider may have been billed as out-of-network.
What My Plan Paid	The portion of the Allowed Charges that Cigna paid directly to the provider.47	Does this amount reflect your plan’s cost-sharing rules (e.g., 80% coinsurance)?
What I Owe / Your Responsibility	The amount the EOB calculates that you are responsible for paying (your copay, deductible, and coinsurance).48	This is the most critical number. Does it correctly reflect your deductible status? Is the math correct? This is where errors often occur.7
Remark Code	An alphanumeric code that explains why a decision was made (e.g., why a service was denied or paid a certain way).47	Always look up these codes. They contain the justification for Cigna’s actions and are the key to understanding and appealing a denial.
Deductible Status	A running total of how much you have paid toward your individual and family deductibles for the year.46	Compare this to your own records of payments. This is where a user found Cigna was miscalculating their status for months.7
Out-of-Pocket Status	A running total of how much you have paid toward your out-of-pocket maximum for the year.46	Check this for accuracy, as it determines when your plan starts paying 100% of costs.

Chapter 6: The Chasm of Discontent – Analyzing Widespread User Complaints

The gap between Cigna’s marketing and the member experience is most evident in the vast number of public complaints.

These are not random anecdotes but form clear, recurring patterns of systemic issues.

Category 1: Claims Processing and Financial Errors

Egregious errors in financial calculations appear to be a common occurrence.

One of the most detailed complaints describes how a member’s family had clearly met their $3,300 deductible, yet for months afterward, Cigna’s system incorrectly processed claims as if the deductible had not been met, resulting in over $2,100 in erroneous bills.⁷

The company’s explanation was simply “computer error”.⁷

This points to a significant flaw in Cigna’s automated processing systems, which one user notes are “prone to errors”.⁶

The burden of detecting these costly mistakes and spending hours on the phone to correct them falls entirely on the member.

Category 2: Denial of Care and Pre-Authorization Hurdles

A more alarming pattern involves the denial of necessary medical care.

User reports detail Cigna denying claims for life-saving autoimmune medication ¹², human growth hormone for a child who had been on it for years ¹¹, and even cancer treatment recommended by an oncologist.¹²

The pre-authorization process, which is required for many services, is described as a “nightmare” that can take months, delaying critical surgeries and treatments.¹¹

This practice is the most direct manifestation of a system that prioritizes cost control, forcing doctors and patients into time-consuming appeals and “peer-to-peer” reviews to justify care that should be routine.¹¹

Category 3: Inaccurate Network Information

A frequent and financially dangerous complaint is that Cigna’s own provider directory is unreliable.

Members report using the myCigna portal to find an “in-network” provider, only to receive large, unexpected bills because the provider was actually out-of-network.¹¹

This “surprise billing” can result from outdated information in Cigna’s database or a failure to properly integrate data from its delegated partners like EyeMed.

The online tool, meant to be a source of truth, becomes a financial trap for the unsuspecting member.

Category 4: Customer Service Failures

Perhaps the most universal complaint revolves around the failure of Cigna’s customer service.

The experience is consistently described as an exercise in futility, involving long hold times, being hung up on, receiving conflicting information from different representatives, and being promised callbacks from supervisors that never materialize.⁶

Representatives often seem unable to resolve issues or even reach the internal departments responsible for claims processing.¹¹

This creates a deliberately frustrating barrier that deters inquiry and makes it exceedingly difficult for members to resolve the errors generated by other parts of the Cigna system.

Common Cigna Complaint	Example from Research	Proactive Member Strategy
Incorrect Deductible/Financial Calculation	A user was billed for $2,100 in services that should have been covered after their deductible was met, an error Cigna blamed on its computers.7	Maintain your own spreadsheet of medical expenses and payments. Audit every EOB against your records and your plan’s cost-sharing rules.
Pre-Authorization Denial for Necessary Care	Cigna denied a member’s life-saving medication for an autoimmune disease, forcing them to go without until an appeal could be fought.12	Understand your plan’s pre-authorization requirements.52 Work with your doctor’s office to submit all necessary documentation early and follow up relentlessly with Cigna.
Inaccurate “In-Network” Provider Directory	A member was charged $1,635 for dental work that should have been under $100 because the dentist listed as in-network in Cigna’s search was not.11	Never rely solely on the Cigna website. Before any appointment, call the provider’s billing office and verbally confirm they are currently in-network with your specific Cigna plan (e.g., “Cigna PPO,” not just “Cigna”).
Unresponsive/Ineffective Customer Service	Users report being run in circles, being hung up on, and being unable to escalate issues to a manager who can actually solve the problem.6	At the start of every call, get the representative’s name and a call reference number. If you are not getting a resolution, politely end the call and try again. Use formal, written channels like the secure message portal on myCigna.
Failure to Issue Reimbursement	An international member had over $10,000 in approved claims but never received payment because Cigna repeatedly made errors sending the money to their bank.51	For any out-of-network claims requiring reimbursement, submit claims immediately. Follow up regularly on their status. If payment is delayed, escalate immediately through written channels and consider filing a formal grievance.

Part III: A Strategic Playbook for the Cigna Member

This final section synthesizes the preceding analysis into a set of actionable strategies for members to protect their health and financial interests.

Chapter 7: Proactive Defense – Strategies for Minimizing Friction with Cigna

The most effective way to deal with Cigna’s systemic issues is to anticipate them.

A proactive, defensive posture is required.

• Documentation is Everything: The foundation of self-advocacy is a meticulous paper trail. Maintain a dedicated log or notebook for all interactions with Cigna. For every phone call, record the date, time, the name of the representative, and a call reference number. Summarize the conversation and the resolution promised. This log becomes invaluable evidence in an appeal.
• Never Trust, Always Verify: Given the documented inaccuracies in Cigna’s provider directory ¹¹, members must adopt a policy of independent verification. Before scheduling any appointment, especially with a new specialist, the member or their doctor’s office must call the provider’s billing department and ask a specific question: “Do you currently participate in the network for the Cigna [insert your specific plan name, e.g., PPO, EPO] plan?” A generic “Do you take Cigna?” is insufficient.
• Master the Pre-Authorization Process: Members must be aware of which services under their plan require prior authorization, also known as precertification.⁵² This information is in the plan documents. For any such procedure or medication, the process should be initiated as early as possible. While the doctor’s office is responsible for submitting the request, the member must often act as the project manager, following up with both the provider and Cigna to ensure the authorization is secured before care is rendered.
• Audit Every EOB: An EOB should not be filed away without scrutiny. It must be treated like a bank statement or credit card bill. Compare the services listed to the care that was actually received. Check the application of the deductible and coinsurance against your plan rules and your own payment records. Question every denial and look up every “Remark Code” to understand the justification.⁷ Early detection of errors is the best defense against future billing problems.

Chapter 8: When Things Go Wrong – A Step-by-Step Guide to the Appeals and Grievance Process

When proactive measures fail and a claim is denied or processed incorrectly, members must be prepared to engage with Cigna’s formal dispute resolution process.

The Official Channels

Cigna provides a multi-level process for appealing a decision.⁵³

1. Step 1: Informal Resolution: The first step recommended by Cigna is to call customer service to try and resolve the issue informally.⁵⁴
2. Step 2: Formal Internal Appeal: If the issue is not resolved, the member has the right to file a formal internal appeal. This must typically be done within 180 days of the initial denial.⁵⁴ The appeal can be submitted by phone, by mail to the National Appeals Unit, or online via a grievance form.⁵³ It is crucial to submit all supporting documentation, such as medical records and letters from the treating physician.
3. Step 3: Expedited Appeal: In urgent situations where waiting the standard review period would “seriously jeopardize your life or health,” a member can request an expedited appeal. If approved, Cigna must provide a decision within 72 hours.⁵³
4. Step 4: External Review: If Cigna upholds its denial after the internal appeal process is exhausted, the member has the right to an independent external review. This takes the case to a third party, and the insurance company no longer has the final say on whether to pay the claim.⁵⁵

The Unofficial Reality and Strategy

While the official channels exist, user experience suggests they can be another layer of bureaucracy.

A successful appeal requires persistence and a broader strategy.

• Expect a Fight: Members should assume that the appeals process will be difficult and time-consuming. It is often not a simple matter of correcting an error but of overcoming a systemic inclination to deny payment.⁹
• Leverage External Pressure: When the internal process fails or stalls, members should escalate the issue externally. Filing a formal complaint with the Better Business Bureau ⁵⁶ and, more importantly, with the governing regulatory body in their state—such as the Department of Insurance or the Department of Managed Health Care—can be highly effective.⁵³ These agencies have the authority to investigate and compel the insurer to act, and filing a complaint creates a public record of the company’s conduct.

Conclusion: A Final Verdict on Cigna – Balancing Value, Risk, and Member Advocacy

The analysis of Cigna’s benefits and operational realities presents a starkly divided picture.

On one hand, the company offers a comprehensive and modern portfolio of products.

Its investments in wellness programs, virtual care partnerships, and integrated behavioral health are genuinely valuable and align with the future of healthcare.⁵

These offerings can and do provide significant benefits to members who can access them effectively.

On the other hand, Cigna is plagued by systemic operational failures in its most fundamental duties: accurately processing claims, providing reliable network information, and delivering accessible customer service.

The chasm between the company’s strong financial performance ¹⁰ and its abysmal customer satisfaction ratings ¹¹ is not a paradox; it is the predictable result of a business model where friction is profitable.

The automated, siloed, and often outsourced systems create barriers that, whether by explicit design or as a functional consequence, contain costs by placing an immense burden of administration and advocacy on the member.

Therefore, a final recommendation on Cigna is not a simple “good” or “bad.” The benefits can be substantial, but they are accessible only to a member who is prepared for the inherent risks.

Choosing or using a Cigna health plan requires a clear-eyed understanding of this dynamic.

The member must be willing and able to become a vigilant, organized, and relentlessly persistent advocate for their own care.

Within the Cigna ecosystem, one is not simply a patient or a customer; one must be the project manager of their own healthcare, and Cigna is often the most challenging and unpredictable variable in the equation.

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