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Cigna Health and Life Insurance Company

Cigna Connect 0 ($0 Telehealth)

Plan Overview

Medical Deductable
  • Individual: $0
  • Family: $0
  • Per Person: $0
Prescription Drug Deductible
  • Individual: $800
  • Family: $1,600
  • Per Person: $800
Combined Medical and Drug Out of Pocket Maximum
  • Individual: $8,700
  • Family: $17,400
  • Per Person: $8,700

Office Visit

Primary Doctor
  • CoPay: $30.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Virtual medical visit with a Dedicated Virtual Care Physician is covered at No Charge. Refer to the policy for more information.
Specialist
  • CoPay: $85.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Includes Mental Health Office Visits and Substance Use Disorder Office Visits.

Prescription Drug Information

Preferred Brand Drugs
  • CoPay: Not Applicable
  • CoInsurance: 40.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: Up to a 30-day supply at any Participating Pharmacy or up to a 90-day supply at a Designated 90 day Retail Pharmacy. Formulary Diabetic Supplies are covered at no charge. Refer to the prescription drug list for more information.
Non Preferred Brand Drugs
  • CoPay: Not Applicable
  • CoInsurance: 50.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: Up to a 30-day supply at any Participating Pharmacy or up to a 90-day supply at a Designated 90 day Retail Pharmacy. Formulary Diabetic Supplies are covered at no charge. Refer to the prescription drug list for more information.
Generic Drugs
  • CoPay: $15.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Cost sharing shown applies to Tier 1-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 2-Generic Drugs, which may apply a higher cost share. Up to a 30-day supply at any Participating Pharmacy or up to a 90-day supply at a Designated 90 day Retail Pharmacy. You pay a copayment for each 30-day supply. Formulary Diabetic Supplies are covered at no charge. Refer to the prescription drug list for more information.
Specialty Drugs
  • CoPay: Not Applicable
  • CoInsurance: 50.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: Including other high cost drugs. Up to a 30-day supply at any Participating Pharmacy or up to a 30-day supply at a Designated 90 day Retail Pharmacy.

Inpatient Coverage

Hospital Services
  • CoPay: Not Applicable
  • CoInsurance: 50.00%
  • Covered: Covered
Inpatient Services
  • CoPay: Not Applicable
  • CoInsurance: 50.00%
  • Covered: Covered

Emergency and Urgent Care

Emergency Room
  • CoPay: Not Applicable
  • CoInsurance: 50.00%
  • Covered: Covered
  • Benefit Explanation: Out of Network: You pay the same level as In-network if it is an emergency as defined in your plan, otherwise Not covered.
Urgent Care Facility
  • CoPay: $85.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Out of Network: You pay the same level as In-network if it is an emergency as defined in your plan, otherwise Not covered.

Maternity

Labor and Delivery Hospital Stay
  • CoPay: Not Applicable
  • CoInsurance: 50.00%
  • Covered: Covered
Pre and Postnatal Office Visit
  • CoPay: Not Applicable
  • CoInsurance: 50.00%
  • Covered: Covered

Vision

Routine Eye Exams For Children
  • CoPay: Not Applicable
  • CoInsurance: No Charge
  • Covered: Covered
  • Limit Quantity: 1
  • Limit Unit : Visit(s) per Year

Major Dental Care

Routine Dental Checkups for Children
  • Covered: Not Covered
Basic Dental Care - Child
  • Covered: Not Covered
Major Dental Care - Child
  • Covered: Not Covered
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Cigna HealthCare of Arizona, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of North Carolina, Inc. and Cigna Dental Health, Inc. The Cigna name, logo and other Cigna marks are owned by Cigna Intellectual Property, Inc.
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