2021 Cigna Connect Silver – Diabetes Care Options
- Overview
- Cigna Connect 40-4 Diabetes Care
- Cigna Connect 550-3 Diabetes Care
- Cigna Connect 2600-2 Diabetes Care
- Cigna Connect 3500 Diabetes Care
Cigna Connect 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 Name | Cigna Connect 40-4 | Cigna connect 550-3 | Cigna connect 2600-2 | Cigna connect 3500 |
| Deductible | $40/$80 | $550/$1,100 | $2,600/$5,200 | $3,500/$7,000 |
| Coinsurance | 10% | 20% | 30% | 30% |
| Out-of-Pocket Maximum | $1,500/$3,000 | $2,850/$5,800 | $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 Connect 40-4 Diabetes Care
| Important Questions | Answers | Why this Matters: |
| What is the overall deductible? | $40 person/ $80 family | Generally, 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? |
No | You don’t have to meet deductibles for specific services |
| What is the out-of-pocket limit for this plan? |
$1,500 person/ $3,000 family | The 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? | Yes | This 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 Event | Services You May Need |
Your cost if you use |
Your cost if you use |
Limitations & Exceptions, & Other Important Information |
| If you visit a health care provider’s office or clinic | Primary care visit to treat an injury or illness |
$0 copayment /visit; |
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 test | Diagnostic 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)/ |
Not covered | 90 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 |
| Generic drugs |
$15 copayment (retail)/ |
Not covered | ||
| Preferred brand drugs |
$30 copayment (retail)/ |
Not covered |
||
| Non-preferred drugs |
50% coinsurance |
Not covered |
||
| Specialty drugs and other high cost drugs | 40% 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; |
$15 copayment /visit; |
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 services | 10% coinsurance |
Not covered |
None |
| Inpatient services |
10% coinsurance |
Not covered |
None | |
| If you are pregnant | Office 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
None
None |
| Rehabilitation services |
$0 copayment /visit |
Not covered |
||
| Habilitation services |
$0 copayment /visit |
Not covered |
||
| Skilled nursing care |
10% coinsurance |
Not covered |
||
| Durable medical equipment |
10% coinsurance |
Not covered |
None | |
| Hospice service | 10% 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.) |
|
| Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) |
|
Cigna Connect 550-3 Diabetes Care
| Important Questions | Answers | Why this Matters: |
| What is the overall deductible? | $550 person/ $1,100 family | Generally, 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? |
No | You don’t have to meet deductibles for specific services |
| What is the out-of-pocket limit for this plan? |
$2,850 person/ $5,700 family | The 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? | Yes | This 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 Event | Services You May Need |
Your cost if you use |
Your cost if you use |
Limitations & Exceptions, & Other Important Information |
| If you visit a health care provider’s office or clinic | Primary care visit to treat an injury or illness |
$0 copayment /visit; |
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 test | Diagnostic 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)/ |
Not covered | 90 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 |
| Generic drugs |
$15 copayment (retail)/ |
Not covered | ||
| Preferred brand drugs |
$55 copayment (retail)/ |
Not covered |
||
| Non-preferred drugs |
50% coinsurance |
Not covered |
||
| Specialty drugs and other high cost drugs | 40% 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; |
$25 copayment /visit; |
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 services | 20% coinsurance |
Not covered |
None |
| Inpatient services |
20% coinsurance |
Not covered |
None | |
| If you are pregnant | Office 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
None
None |
| Rehabilitation services |
$0 copayment /visit |
Not covered |
||
| Habilitation services |
$0 copayment /visit |
Not covered |
||
| Skilled nursing care |
20% coinsurance |
Not covered |
||
| Durable medical equipment |
20% coinsurance |
Not covered |
None | |
| Hospice service | 20% 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.) |
|
| Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) |
|
Cigna Connect 2600-2 Diabetes Care
| Important Questions | Answers | Why this Matters: |
| What is the overall deductible? | $2,600 person/ $5,200 family | Generally, 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? |
No | You don’t have to meet deductibles for specific services |
| What is the out-of-pocket limit for this plan? |
$6,800 person/ $13,600 family | The 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? | Yes | This 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 Event | Services You May Need |
Your cost if you use |
Your cost if you use |
Limitations & Exceptions, & Other Important Information |
| If you visit a health care provider’s office or clinic | Primary care visit to treat an injury or illness |
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 test | Diagnostic 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)/ |
Not covered | 90 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 |
| Generic drugs |
$20 copayment (retail)/ |
Not covered | ||
| Preferred brand drugs |
$70 copayment (retail)/ |
Not covered |
||
| Non-preferred drugs |
50% coinsurance |
Not covered |
||
| Specialty drugs and other high cost drugs | 40% 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; |
$30 copayment /visit; |
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 services | 30% coinsurance |
Not covered |
None |
| Inpatient services |
30% coinsurance |
Not covered |
None | |
| If you are pregnant | Office 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
None
None |
| Rehabilitation services |
$0 copayment /visit |
Not covered |
||
| Habilitation services |
$0 copayment /visit |
Not covered |
||
| Skilled nursing care |
30% coinsurance |
Not covered |
||
| Durable medical equipment |
30% coinsurance |
Not covered |
None | |
| Hospice service | 30% 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.) |
|
| Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) |
|
Cigna Connect 3500 Diabetes Care
| Important Questions | Answers | Why this Matters: |
| What is the overall deductible? | $3,500 person/ $7,000 family | Generally, 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? |
No | You don’t have to meet deductibles for specific services |
| What is the out-of-pocket limit for this plan? |
$8,550 person/ $17,100 family | The 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? |
Yes | This 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 Event | Services You May Need |
Your cost if you use |
Your cost if you use |
Limitations & Exceptions, & Other Important Information |
| If you visit a health care provider’s office or clinic | Primary care visit to treat an injury or illness |
$10 copayment/visit |
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 test | Diagnostic 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)/ |
Not covered | 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. You pay copayment for each 30-day supply (retail).
Limited to a 30 day supply at any participating |
| Generic drugs |
$20 copayment (retail)/ |
Not covered | ||
| Preferred brand drugs |
$70 copayment (retail)/ |
Not covered |
||
| Non-preferred drugs |
50% coinsurance (retail/home delivery) |
Not covered |
||
| Specialty drugs and other high cost drugs | 40% 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 |
$35 copayment/visit |
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 services | 30% coinsurance |
Not covered |
None |
| Inpatient services |
30% coinsurance |
Not covered |
None | |
| If you are pregnant | Office 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
None
None |
| Rehabilitation services |
$10 copayment /visit |
Not covered |
||
| Habilitation services |
$10 copayment /visit |
Not covered |
||
| Skilled nursing care |
30% coinsurance |
Not covered |
||
| Durable medical equipment |
30% coinsurance |
Not covered |
None | |
| Hospice service | 30% 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.) |
|
| Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) |
|
