Cigna Health and Life Insurance Company

Cigna Connect HSA 7000

Plan Overview

Combined Medical and Drug Deductible
  • Individual: $7,000
  • Family: $14,000
  • Per Person: $7,000
Combined Medical and Drug Out of Pocket Maximum
  • Individual: $7,000
  • Family: $14,000
  • Per Person: $7,000

Office Visit

Primary Doctor
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: Virtual medical visit (online visit) with a Dedicated Virtual Care Physician is covered at No Charge. In home visits by a Primary Care Physician are covered, refer to the policy for more information.
Specialist
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • Covered: Covered

Prescription Drug Information

Preferred Brand Drugs
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: 30 day supply at any participating pharmacy or up to a 90 day supply at a 90 day retail pharmacy. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30 day supply. 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: 0.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: 30 day supply at any participating pharmacy or up to a 90 day supply at a 90 day retail pharmacy. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30 day supply.
Generic Drugs
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • 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. 30 day supply at any participating pharmacy or up to a 90 day supply at a 90 day retail pharmacy. Formulary Diabetic Supplies are covered at no charge. Refer to the prescription drug list for more information.
Specialty Drugs
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: Including other high cost drugs. 30 day supply at any participating pharmacy or up to a 30 day supply at a 90 day retail pharmacy.

Inpatient Coverage

Hospital Services
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: Inpatient Room and Board, Lab and X-ray, Operating Room, etc. Out-of-Network: Emergency Services covered at In-Network cost share until transferable to an In-Network Hospital; if transferred to a Non-Participating Hospital services will no longer be covered and you will be responsible for 100% of the charges.
Inpatient Services
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • Covered: Covered

Emergency and Urgent Care

Emergency Room
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • Covered: Covered
Urgent Care Facility
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • Covered: Covered

Maternity

Labor and Delivery Hospital Stay
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • Covered: Covered
Pre and Postnatal Office Visit
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • 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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