2021 Cigna Plus Silver Diabetes Care Options


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Cigna Plus Diabetes Care Plans

Cigna’s new Diabetes Care Plans offer more ways to save with $0 out-of-pockets costs on diabetes supplies and equipment in addition to their standard diabetes coverage available on all of their Individual and Family Health Insurance Plans.

Patient Assurance ProgramSM

If you rely on insulin for diabetes, it can be challenging to afford. With Cigna’s Patient Assurance Program, you may be eligible to get coverage for a 30-day supply of a Preferred Brand covered, eligible insulin for no more than a $25 out-of-pocket cost. This program reduces out-of-pocket costs for insulin by an average of 40% or more.*

Diabetes Coverage Plans allows you to pay $0** for: 

  • Diabetes supplies on the Cigna drug list
  • Diabetes Education and Self-Management Training
  • Diabetes Lab: A1C and Nephropathy
  • Diabetes retinal eye exam
  • Metformin

Cigna Connect Diabetes Care Plans Overview

Plan NameCigna Plus w/ Northwestern Medicine 40-4Cigna Plus w/ Northwestern Medicine 550-3Cigna Plus w/ Northwestern Medicine 2600-2Cigna Plus w/ Northwestern Medicine 3500
Deductible$40/$80$550/$1,100$2,600/$5,200$3,500/$7,000
Coinsurance10%20%30%30%
Out-of-Pocket Maximum$1,500/$3,000$2,850/$5,700$6,800/$13,600$8,550/$17,100
PCP/Specialist$0/10%$0/20%$0/30%$10/30%

 

Cigna Connect Diabetes Care Plans are not available in Colorado.

*Express Scripts International analysis of claims, 2019.

**$0 coverage is after the deductible is met on HSA plans.

 

Cigna Plus with Northwestern Medicine 3500 Diabetes Care

Summary of Benefits

Important Questions Answers Why this Matters:
What is the overall deductible?$3,500 person/ $7,000 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, Prescription drugs 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

$10 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

30% 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)

30% coinsurance

Not covered

None
Imaging (CT / PET scans, MRIs)

30% 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

$5 copayment (retail)/
$15 copayment (home
delivery); deductible
does not apply

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. You pay copayment for each 30-day supply (retail). 

 

 

 

 

 

Limited 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

$20 copayment (retail)/
$60 copayment (home
delivery); deductible
does not apply

Not covered
Preferred brand drugs

$70 copayment (retail)/
$210 copayment (home
delivery); deductible
does not apply

Not covered

Non-preferred drugs

50% coinsurance (retail/home delivery)

Not covered

Specialty drugs and other high cost drugs40% coinsurance
(retail/home delivery)
 Not covered
If you have outpatient
surgery
Facility fee (e.g., ambulatory surgery center)30% coinsurance

Not covered

None
Physician/surgeon fees

30% 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

30% coinsurance

30% coinsurance

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

$35 copayment/visit
deductible does not
apply

$35 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)

30% coinsurance

Not covered

None
Physician/surgeon fee

30% coinsurance

Not covered

If you have mental
health, behavioral
health, or substance
abuse needs
Outpatient services30% coinsurance

Not covered

None
Inpatient services

30% coinsurance

Not covered

None
If you are pregnantOffice visits

30% 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

30% 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

30% 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

30% coinsurance

Not covered

None

 

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

 

 

 

 

 

 

 

 

None

 

 

 

 

 

 

 

None

Rehabilitation services

$10 copayment /visit
physical and
occupational therapy;
deductible does not
apply; 30% coinsurance
all other services.

Not covered

Habilitation services

$10 copayment /visit
physical and
occupational therapy:
deductible does not
apply; 30% coinsurance
all other services.

Not covered

Skilled nursing care

30% coinsurance

Not covered

Durable medical equipment

30% coinsurance

Not covered

None
Hospice service30% 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 2600-2 Diabetes Care

Summary of Benefits

Important Questions Answers Why this Matters:
What is the overall deductible?$2,600 person/ $5,200 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?
$6,800 person/ $13,600 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

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

Not covered

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

30% 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)

30% coinsurance

Not covered

None
Imaging (CT / PET scans, MRIs)

30% 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

$5 copayment (retail)/
$15 copayment (home
delivery); deductible
does not apply

Not covered90 day retail pharmacy/home Limited to a 30 day supply at any participating pharmacy or up to a 90 day supply at a designated delivery. You pay copayment for each 30-day supply (retail).

 

 

 

 

 

 

 

 

Limited 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

$20 copayment (retail)/
$60 copayment (home
delivery); deductible
does not apply

Not covered
Preferred brand drugs

$70 copayment (retail)/
$210 copayment (home
delivery); deductible
does not apply

Not covered

Non-preferred drugs

50% coinsurance
(retail/home delivery)

Not covered

Specialty drugs and other high cost drugs40% coinsurance
(retail/home delivery)
 Not covered
If you have outpatient
surgery
Facility fee (e.g., ambulatory surgery center)30% coinsurance

Not covered

None
Physician/surgeon fees

30% 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

30% coinsurance

30% coinsurance

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

$30 copayment /visit;
deductible does not
apply

$30 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)

30% coinsurance

Not covered

None
Physician/surgeon fee

30% coinsurance

Not covered

If you have mental
health, behavioral
health, or substance
abuse needs
Outpatient services30% coinsurance

Not covered

None
Inpatient services

30% coinsurance

Not covered

None
If you are pregnantOffice visits

30% 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

30% 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

30% 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

30% coinsurance

Not covered

None

 

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

 

 

None

 

None

Rehabilitation services

$0 copayment /visit
physical and
occupational therapy;
deductible does not
apply; 30% coinsurance
all other services.

Not covered

Habilitation services

$0 copayment /visit
physical and
occupational therapy:
deductible does not
apply; 30% coinsurance
all other services.

Not covered

Skilled nursing care

30% coinsurance

Not covered

Durable medical equipment

30% coinsurance

Not covered

None
Hospice service30% 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-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

Cigna Connect 550-3 Diabetes Care

Summary of Benefits

Important Questions Answers Why this Matters:
What is the overall deductible?$550 person/ $1,100 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, Prescription drugs 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?
$2,850 person/ $5,700 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 copayment /visit;
deductible does not
apply. Includes a Dedicated Virtual medical visit with
a Dedicated Virtual
Care Physician.

Not covered

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

20% 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)

20% coinsurance

Not covered

None
Imaging (CT / PET scans, MRIs)

20% 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

$5 copayment (retail)/
$15 copayment (home
delivery); deductible
does not apply

Not covered90 day retail pharmacy/home Limited to a 30 day supply at any participating pharmacy or up
to a 90 day supply at a designated delivery. You pay copayment for each 30-day supply (retail). 

 

 

 

 

Limited 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

$15 copayment (retail)/
$45 copayment (home
delivery); deductible
does not apply

Not covered
Preferred brand drugs

$55 copayment (retail)/
$165 copayment (home
delivery); deductible
does not apply

Not covered

Non-preferred drugs

50% coinsurance
(retail/home delivery)

Not covered

Specialty drugs and other high cost drugs40% coinsurance
(retail/home delivery)
 Not covered
If you have outpatient
surgery
Facility fee (e.g., ambulatory surgery center)20% coinsurance

Not covered

None
Physician/surgeon fees

20% coinsurance

Not covered

If you need immediate
medical attention
Emergency room care

20% coinsurance

20% 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

20% coinsurance

20% coinsurance

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

$25 copayment /visit;
deductible does not
apply

$25 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)

20% coinsurance

Not covered

None
Physician/surgeon fee

20% coinsurance

Not covered

If you have mental
health, behavioral
health, or substance
abuse needs
Outpatient services20% coinsurance

Not covered

None
Inpatient services

20% coinsurance

Not covered

None
If you are pregnantOffice visits

20% 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

20% 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

20% 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

20% coinsurance

Not covered

None

 

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

 

 

None

 

None

Rehabilitation services

$0 copayment /visit
physical and
occupational therapy;
deductible does not
apply; 20% coinsurance
all other services.

Not covered

Habilitation services

$0 copayment /visit
physical and
occupational therapy:
deductible does not
apply; 20% coinsurance
all other services.

Not covered

Skilled nursing care

20% coinsurance

Not covered

Durable medical equipment

20% coinsurance

Not covered

None
Hospice service20% 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-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

Cigna Plus with Northwestern Medicine 40-4 Diabetes Care

Summry of Benefits

Important Questions Answers Why this Matters:
What is the overall deductible?$40 person/ $80 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, Prescription drugs 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?
$1,500 person/ $3,000 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 copayment /visit;
deductible does not
apply. Includes a Dedicated Virtual medical visit with
a Dedicated Virtual
Care Physician.

Not covered

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

10% 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)

10% coinsurance

Not covered

None
Imaging (CT / PET scans, MRIs)

10% 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 copayment (retail)/
$0 copayment (home
delivery); deductible
does not apply

Not covered90 day retail pharmacy/home Limited to a 30 day supply at any participating pharmacy or up
to a 90 day supply at a designated delivery. You pay copayment for each 30-day supply (retail). 

 

 

 

Limited 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

$15 copayment (retail)/
$45 copayment (home
delivery); deductible
does not apply

Not covered
Preferred brand drugs

$30 copayment (retail)/
$90 copayment (home
delivery); deductible
does not apply

Not covered

Non-preferred drugs

50% coinsurance
(retail/home delivery)

Not covered

Specialty drugs and other high cost drugs40% coinsurance
(retail/home delivery)
 Not covered
If you have outpatient
surgery
Facility fee (e.g., ambulatory surgery center)10% coinsurance

Not covered

None
Physician/surgeon fees

10% coinsurance

Not covered

If you need immediate
medical attention
Emergency room care

10% coinsurance

10% 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

10% coinsurance

10% coinsurance

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

$15 copayment /visit;
deductible does not
apply

$15 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)

10% coinsurance

Not covered

None
Physician/surgeon fee

10% coinsurance

Not covered

If you have mental
health, behavioral
health, or substance
abuse needs
Outpatient services10% coinsurance

Not covered

None
Inpatient services

10% coinsurance

Not covered

None
If you are pregnantOffice visits

10% 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

10% 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

10% 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

10% coinsurance

Not covered

None

 

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

 

 

None

 

None

Rehabilitation services

$0 copayment /visit
physical and
occupational therapy;
deductible does not
apply; 10% coinsurance
all other services.

Not covered

Habilitation services

$0 copayment /visit
physical and
occupational therapy:
deductible does not
apply; 10% coinsurance
all other services.

Not covered

Skilled nursing care

10% coinsurance

Not covered

Durable medical equipment

10% coinsurance

Not covered

None
Hospice service10% 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-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