2021 Cigna Plus Bronze Options


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Cigna Plus Bronze Overview

Bronze plans usually have the lowest monthly premiums but the highest costs when you get care. These plans are good for individuals that usually use few medical services, don’t see a doctor often, and mostly want protection from very high costs if they get seriously sick or injured.

 

Plan NameCigna Connect -0Cigna Connect 6750Cigna Connect 7150Cigna Connect 8550
Deductible$0$6,750/$13,500$7,150/$14,000$8,550/$17,100
Coinsurance0%50%50%0%
Out-of-Pocket Maximum$8,550/$17,100$8,550/$17,100$8,550/$17,100$8,550/$17,100
PCP/Specialist0%$50/$9050%0%

 Cigna Plus with Northwestern Medicine 8550

Summary of Benefits

Important Questions Answers Why this Matters:
What is the overall deductible?$8,550 person/ $17,100 familyGenerally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.
Are there services covered before you meet your deductible?Yes. Preventive care and eye
exam/glasses for children are
covered before you meet your
deductible.
This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive
services at https://www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other
deductibles for specific
services?
NoYou don’t have to meet deductibles for specific services
What is the out-of-pocket
limit for this plan?
$8,550 person/ $17,100 familyThe out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.
What is not included in
the out-of-pocket limit?
Premiums, balance-billing charges, penalties for failure to obtain preauthorization for services and health care this plan doesn’t cover.Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Will you pay less if you use a network provider? Yes. See www.cigna.com/ifpproviders or call  1-866-494-2111
for a list of network providers.
This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
Do you need a referral to
see a specialist?
YesThis plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist.
Common Medical EventServices You May Need

Your cost if you use
a Participating
Provider (You will pay the least)

Your cost if you use
a Non-Participating
Provider (You will pay the most)

Limitations & Exceptions, & Other Important Information
If you visit a health care provider’s office or clinicPrimary care visit to treat an injury or illness

0% coinsurance. Virtual medical visit with a Dedicated Virtual Care
Physician No charge

Not covered

Refer to the policy for more information about Virtual Care Services.
Specialist visit

0% coinsurance

Not covered

None
Preventive care/screening/immunization

No charge

Not covered

You may have to pay for services that aren’t preventive. Ask your provider if the services are needed are preventive. Then check what your plan will pay for.
If you have a testDiagnostic test (x-ray, blood work)

0% coinsurance

Not covered

None
Imaging (CT / PET scans, MRIs)

0% coinsurance

Not covered

None
If you need drugs to
treat your illness or
condition. More information about
prescription drug
coverage is available at
www.cigna.com/ifpdrug-list
Preferred generic drugs

0% coinsurance
(retail/home delivery)

Not coveredLimited to a 30 day supply at any participating
pharmacy or up to a 90 day supply at a
designated 90 day retail pharmacy/home
delivery.
Generic drugs

0% coinsurance
(retail/home delivery)

Not covered
Preferred brand drugs

0% coinsurance
(retail/home delivery)

Not covered

Non-preferred drugs

0% coinsurance
(retail/home delivery)

Not covered

Specialty drugs and other high cost drugs0% coinsurance
(retail/home delivery)
 Not covered
If you have outpatient
surgery
Facility fee (e.g., ambulatory surgery center)0% coinsurance

Not covered

None
Physician/surgeon fees

0% coinsurance

Not covered

If you need immediate
medical attention
Emergency room care

0% coinsurance

0% coinsurance

You pay the same level as In-network if it is an emergency as defined in your plan, otherwise not covered.
Emergency medical transportation

0% coinsurance

0% coinsurance

You pay the same level as In-network if it is an emergency as defined in your plan, otherwise not covered.
Urgent care

0% coinsurance

0% coinsurance

You pay the same level as In-network if it is an emergency as defined in your plan, otherwise not covered.
If you have a hospital
stay
Facility fee (e.g., hospital room)

0% coinsurance

Not covered

None
Physician/surgeon fee

0% coinsurance

Not covered

If you have mental
health, behavioral
health, or substance
abuse needs
Outpatient services0% coinsurance

Not covered

None
Inpatient services

0% coinsurance

Not covered

None
If you are pregnantOffice visits

0% coinsurance

Not covered

Cost sharing does not apply for preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
Childbirth/delivery professional services

0% coinsurance

Not covered

Cost sharing does not apply for preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
Childbirth/delivery facility services

0% coinsurance

Not covered

Cost sharing does not apply for preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
If you need help
recovering or have other special health needs
Home health care

0% coinsurance

Not covered

None

 

 

 

 

 

 

Cardiac – Limited to a maximum of 36
treatment sessions within a 6 month period.

 

 

 

 

 

 

 

 

None

 

 

 

 

 

 

 

None

Rehabilitation services

0% coinsurance

Not covered

Habilitation services

0% coinsurance

Not covered

Skilled nursing care

0% coinsurance

Not covered

Durable medical equipment

50% coinsurance

Not covered

None
Hospice service50% coinsurance

Not covered

None
If your child needs
dental or eye care
Children’s eye exam

No Charge

Not covered

Children up to age 19. Coverage limited to one exam/year
Children’s glasses

No Charge

Not covered

Children up to age 19. Coverage limited to one pair of glasses/year.
Children’s dental check-upNot CoveredNot CoveredCoverage is available through a stand-alone dental policy

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
  • Acupuncture
  • Cosmetic Surgery
  • Dental care (Adult)
  • Dental care (Child) (coverage available through a stand-alone dental policy)
  • Long-term care
  • Non-emergency care when traveling outside the U.S.
  • Routine eye care (Adult)
  • Routine foot care
  • Weight loss programs
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
  • Bariatric surgery
  • Chiropractic care (limited to 25 visits annual max)
  • Elective abortion
  • Hearing aids (limited to 1 hearing aid per ear every 2 years)
  • Infertility treatment
  • Private-duty nursing

Cigna Plus with Northwestern Medicine 7150

Summary of Benefits

Important Questions Answers Why this Matters:
What is the overall deductible?$7,150 person/ $14,300 familyGenerally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.
Are there services covered before you meet your deductible?Yes. Preventive care and eye
exam/glasses for children are
covered before you meet your
deductible.
This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive
services at https://www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other
deductibles for specific
services?
NoYou don’t have to meet deductibles for specific services
What is the out-of-pocket
limit for this plan?
$8,550 person/ $17,100 familyThe out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.
What is not included in
the out-of-pocket limit?
Premiums, balance-billing charges, penalties for failure to obtain preauthorization for services and health care this plan doesn’t cover.Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Will you pay less if you use a network provider? Yes. See www.cigna.com/ifpproviders or call  1-866-494-2111
for a list of network providers.
This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
Do you need a referral to
see a specialist?
YesThis plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist.
Common Medical EventServices You May Need

Your cost if you use
a Participating
Provider (You will pay the least)

Your cost if you use
a Non-Participating
Provider (You will pay the most)

Limitations & Exceptions, & Other Important Information
If you visit a health care provider’s office or clinicPrimary care visit to treat an injury or illness

50% coinsurance. Virtual
medical visit with a
Dedicated Virtual Care
Physician No charge

Not covered

Refer to the policy for more information about Virtual Care Services.
Specialist visit

50% coinsurance

Not covered

None
Preventive care/screening/immunization

No charge

Not covered

You may have to pay for services that aren’t preventive. Ask your provider if the services are needed are preventive. Then check what your plan will pay for.
If you have a testDiagnostic test (x-ray, blood work)

50% coinsurance

Not covered

None
Imaging (CT / PET scans, MRIs)

50% coinsurance

Not covered

None
If you need drugs to
treat your illness or
condition. More information about
prescription drug
coverage is available at
www.cigna.com/ifpdrug-list
Preferred generic drugs

50% coinsurance
(retail/home delivery)

Not coveredLimited to a 30 day supply at any participating
pharmacy or up to a 90 day supply at a
designated 90 day retail pharmacy/home
delivery.
Generic drugs

50% coinsurance
(retail/home delivery)

Not covered
Preferred brand drugs

40% coinsurance
(retail/home delivery)

Not covered

Non-preferred drugs

50% coinsurance
(retail/home delivery)

Not covered

Specialty drugs and other high cost drugs50% coinsurance
(retail/home delivery)
 Not covered
If you have outpatient
surgery
Facility fee (e.g., ambulatory surgery center)50% coinsurance

Not covered

None
Physician/surgeon fees

50% coinsurance

Not covered

If you need immediate
medical attention
Emergency room care

50% coinsurance

50% coinsurance

You pay the same level as In-network if it is an emergency as defined in your plan, otherwise not covered.
Emergency medical transportation

50% coinsurance

50% coinsurance

You pay the same level as In-network if it is an emergency as defined in your plan, otherwise not covered.
Urgent care

50% coinsurance

50% coinsurance

You pay the same level as In-network if it is an emergency as defined in your plan, otherwise not covered.
If you have a hospital
stay
Facility fee (e.g., hospital room)

50% coinsurance

Not covered

None
Physician/surgeon fee

50% coinsurance

Not covered

If you have mental
health, behavioral
health, or substance
abuse needs
Outpatient services50% coinsurance

Not covered

None
Inpatient services

50% coinsurance

Not covered

None
If you are pregnantOffice visits

50% coinsurance

Not covered

Cost sharing does not apply for preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
Childbirth/delivery professional services

50% coinsurance

Not covered

Cost sharing does not apply for preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
Childbirth/delivery facility services

50% coinsurance

Not covered

Cost sharing does not apply for preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
If you need help
recovering or have other special health needs
Home health care

50% coinsurance

Not covered

None

 

 

 

 

 

 

Cardiac – Limited to a maximum of 36
treatment sessions within a 6 month period.

 

 

 

 

 

 

 

 

None

 

 

 

 

 

 

 

None

Rehabilitation services

50% coinsurance

Not covered

Habilitation services

50% coinsurance

Not covered

Skilled nursing care

50% coinsurance

Not covered

Durable medical equipment

50% coinsurance

Not covered

None
Hospice service50% coinsurance

Not covered

None
If your child needs
dental or eye care
Children’s eye exam

No Charge

Not covered

Children up to age 19. Coverage limited to one exam/year
Children’s glasses

No Charge

Not covered

Children up to age 19. Coverage limited to one pair of glasses/year.
Children’s dental check-upNot CoveredNot CoveredCoverage is available through a stand-alone dental policy

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
  • Acupuncture
  • Cosmetic Surgery
  • Dental care (Adult)
  • Dental care (Child) (coverage available through a stand-alone dental policy)
  • Long-term care
  • Non-emergency care when traveling outside the U.S.
  • Routine eye care (Adult)
  • Routine foot care
  • Weight loss programs
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
  • Bariatric surgery
  • Chiropractic care (limited to 25 visits annual max)
  • Elective abortion
  • Hearing aids (limited to 1 hearing aid per ear every 2 years)
  • Infertility treatment
  • Private-duty nursing

 Cigna Plus with Northwestern Medicine 6750

Summary of Benefits

Important Questions Answers Why this Matters:
What is the overall deductible?$6,750 person/ $13,500 familyGenerally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.
Are there services covered before you meet your deductible?Yes. Preventive care, office visits
subject to a copayment, Urgent
care and eye exam/glasses for
children are covered before you
meet your deductible.
This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive
services at https://www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other
deductibles for specific
services?
NoYou don’t have to meet deductibles for specific services
What is the out-of-pocket
limit for this plan?
$8,550 person/ $17,100 familyThe out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.
What is not included in
the out-of-pocket limit?
Premiums, balance-billing charges, penalties for failure to obtain preauthorization for services and health care this plan doesn’t cover.Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Will you pay less if you use a network provider? Yes. See www.cigna.com/ifpproviders or call  1-866-494-2111
for a list of network providers.
This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
Do you need a referral to
see a specialist?
YesThis plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist.
Common Medical EventServices You May Need

Your cost if you use
a Participating
Provider (You will pay the least)

Your cost if you use
a Non-Participating
Provider (You will pay the most)

Limitations & Exceptions, & Other Important Information
If you visit a health care provider’s office or clinicPrimary care visit to treat an injury or illness

$50 copayment/visit;
deductible does not apply. Virtual medical visit with a Dedicated
Virtual Care Physician
No charge

Not covered

Refer to the policy for more information about Virtual Care Services.
Specialist visit

$90 copayment/visit
deductible does not
apply.

Not covered

None
Preventive care/screening/immunization

No charge

Not covered

You may have to pay for services that aren’t preventive. Ask your provider if the services are needed are preventive. Then check what your plan will pay for.
If you have a testDiagnostic test (x-ray, blood work)

50% coinsurance

Not covered

None
Imaging (CT / PET scans, MRIs)

50% coinsurance

Not covered

None
If you need drugs to
treat your illness or
condition. More information about
prescription drug
coverage is available at
www.cigna.com/ifpdrug-list
Preferred generic drugs

50% coinsurance
(retail/home delivery)

Not coveredLimited to a 30 day supply at any participating
pharmacy or up to a 90 day supply at a
designated 90 day retail pharmacy/home
delivery.
Generic drugs

50% coinsurance
(retail/home delivery)

Not covered
Preferred brand drugs

40% coinsurance
(retail/home delivery)

Not covered

Non-preferred drugs

50% coinsurance
(retail/home delivery)

Not covered

Specialty drugs and other high cost drugs50% coinsurance
(retail/home delivery)
 Not covered
If you have outpatient
surgery
Facility fee (e.g., ambulatory surgery center)50% coinsurance

Not covered

None
Physician/surgeon fees

50% coinsurance

Not covered

If you need immediate
medical attention
Emergency room care

$1000 copayment/visit

$1000 copayment/visit

You pay the same level as In-network if it is an emergency as defined in your plan, otherwise not covered.
Emergency medical transportation

50% coinsurance

50% coinsurance

You pay the same level as In-network if it is an emergency as defined in your plan, otherwise not covered.
Urgent care

$50 copayment /visit;
deductible does not
apply

$50 copayment /visit;
deductible does not
apply

You pay the same level as In-network if it is an emergency as defined in your plan, otherwise not covered.
If you have a hospital
stay
Facility fee (e.g., hospital room)

50% coinsurance

Not covered

None
Physician/surgeon fee

50% coinsurance

Not covered

If you have mental
health, behavioral
health, or substance
abuse needs
Outpatient services$50 copayment / office
visit; deductible does
not apply and 50%
coinsurance other
outpatient services

Not covered

None
Inpatient services

50% coinsurance

Not covered

None
If you are pregnantOffice visits

50% coinsurance

Not covered

Cost sharing does not apply for preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
Childbirth/delivery professional services

50% coinsurance

Not covered

Cost sharing does not apply for preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
Childbirth/delivery facility services

50% coinsurance

Not covered

Cost sharing does not apply for preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
If you need help
recovering or have other special health needs
Home health care

50% coinsurance

Not covered

None

 

 

 

 

 

 

Cardiac – Limited to a maximum of 36
treatment sessions within a 6 month period.

 

 

 

 

 

 

 

 

None

 

 

 

 

 

 

 

None

Rehabilitation services

50% coinsurance

Not covered

Habilitation services

50% coinsurance

Not covered

Skilled nursing care

50% coinsurance

Not covered

Durable medical equipment

50% coinsurance

Not covered

None
Hospice service50% coinsurance

Not covered

None
If your child needs
dental or eye care
Children’s eye exam

No Charge

Not covered

Children up to age 19. Coverage limited to one exam/year
Children’s glasses

No Charge

Not covered

Children up to age 19. Coverage limited to one pair of glasses/year.
Children’s dental check-upNot CoveredNot CoveredCoverage is available through a stand-alone dental policy

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
  • Acupuncture
  • Cosmetic Surgery
  • Dental care (Adult)
  • Dental care (Child) (coverage available through a stand-alone dental policy)
  • Long-term care
  • Non-emergency care when traveling outside the U.S.
  • Routine eye care (Adult)
  • Routine foot care
  • Weight loss programs
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
  • Bariatric surgery
  • Chiropractic care (limited to 25 visits annual max)
  • Elective abortion
  • Hearing aids (limited to 1 hearing aid per ear every 2 years)
  • Infertility treatment
  • Private-duty nursing

Cigna Plus with Northwestern Medicine-0

Summary of Benefits

Important Questions Answers Why this Matters:
What is the overall deductible?$0 person/ $0 familySee the Common Medical Events chart below for your costs for services this plan covers
Are there services covered before you meet your deductible?Yes.This plan covers some items and services even if you haven’t yet met the deductible amount
Are there other
deductibles for specific
services?
NoYou don’t have to meet deductibles for specific services
What is the out-of-pocket
limit for this plan?
$0 person/ $0 familyThis plan does not have an out-of-pocket limit on your expenses
What is not included in
the out-of-pocket limit?
Premiums, balance-billing charges, penalties for failure to obtain preauthorization for services and health care this plan
doesn’t cover.
This plan does not have an out-of-pocket limit on your expenses
Will you pay less if you use a network provider? Yes. See www.cigna.com/ifpproviders or call 1-866-494-2111
for a list of network providers.
This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
Do you need a referral to see a specialist?YesThis plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist.
Common Medical EventServices You May Need

Your cost if you use
a Participating
Provider (You will pay the least)

Your cost if you use
a Non-Participating
Provider (You will pay the most)

Limitations & Exceptions, & Other Important Information
If you visit a health care provider’s office or clinicPrimary care visit to treat an injury or illness

No Charge. Includes
Virtual medical visit
with a Dedicated
Virtual Care Physician

Not covered

Refer to the policy for more information about Virtual Care Services.
Specialist visit

No Charge

Not covered

None
Preventive care/screening/immunization

No charge

Not covered

You may have to pay for services that aren’t preventive. Ask your provider if the services are needed are preventive. Then check what your plan will pay for.
If you have a testDiagnostic test (x-ray, blood work)

No Charge

Not covered

None
Imaging (CT / PET scans, MRIs)

No Charge

Not covered

None
If you need drugs to
treat your illness or
condition. More information about
prescription drug
coverage is available at
www.cigna.com/ifpdrug-list
Preferred generic drugs

No charge (retail/home
delivery)

Not coveredLimited to a 30 day supply at any participating pharmacy or up to a 90 day supply at a
designated 90 day retail pharmacy/home delivery.
Generic drugs

No charge (retail/home
delivery)

Not covered
Preferred brand drugs

No charge (retail/home
delivery)

Not covered

Non-preferred drugs

No charge (retail/home
delivery)

Not covered

Specialty drugs and other high cost drugsNo charge (retail/home
delivery)
 Not covered
If you have outpatient
surgery
Facility fee (e.g., ambulatory surgery center)No Charge

Not covered

None
Physician/surgeon fees

No Charge

Not covered

If you need immediate
medical attention
Emergency room care

No Charge

No Charge

You pay the same level as In-network if it is an emergency as defined in your plan, otherwise not covered.
Emergency medical transportation

No Charge

No Charge

You pay the same level as In-network if it is an emergency as defined in your plan, otherwise not covered.
Urgent care

No Charge

No Charge

You pay the same level as In-network if it is an emergency as defined in your plan, otherwise not covered.
If you have a hospital
stay
Facility fee (e.g., hospital room)

No Charge

Not covered

None
Physician/surgeon fee

No Charge

Not covered

If you have mental
health, behavioral
health, or substance
abuse needs
Outpatient servicesNo Charge

Not covered

None
Inpatient services

No Charge

Not covered

None
If you are pregnantOffice visits

No Charge

Not covered

Cost sharing does not apply for preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
Childbirth/delivery professional services

No Charge

Not covered

Cost sharing does not apply for preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
Childbirth/delivery facility services

No Charge

Not covered

Cost sharing does not apply for preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
If you need help
recovering or have other special health needs
Home health care

No Charge

Not covered

None

 

Cardiac – Limited to a maximum of 36
treatment sessions within a 6 month period.

 

 

None

 

None

Rehabilitation services

No Charge

Not covered

Habilitation services

No Charge

Not covered

Skilled nursing care

No Charge

Not covered

Durable medical equipment

No Charge

Not covered

None
Hospice serviceNo Charge

Not covered

None
If your child needs
dental or eye care
Children’s eye exam

No Charge

Not covered

Children up to age 19. Coverage limited to one exam/year
Children’s glasses

No Charge

Not covered

Children up to age 19. Coverage limited to one pair of glasses/year.
Children’s dental check-up

Not Covered

Not Covered

Coverage is available through a stand-alone dental policy

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
  • Acupuncture
  • Cosmetic Surgery
  • Dental care (Adult)
  • Dental care (Child) (coverage available through a stand-alone dental policy)
  • Long-term care
  • Non-emergency care when traveling outside the U.S.
  • Routine eye care (Adult)
  • Routine foot care
  • Weight loss programs
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
  • Bariatric surgery
  • Chiropractic care (limited to 25 visits annual max)
  • Elective abortion
  • Hearing aids (limited to 1 hearing aid per ear every 2 years)
  • Infertility treatment
  • Private-duty nursing