Cigna Health and Life Insurance Company

Connect Silver 3000 Indiv Med Deductible

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Plan Overview

Medical Deductible	Individual: $3,000.00 Family: $6000 Per Person: $3000
Prescription Drug Deductible	Individual: $2,000.00 Family: $4000 Per Person: $2000
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,500.00 Family: $17000 Per Person: $8500

Office Visit

Primary Doctor	CoPay: $20.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Refer to the policy for more information about Virtual Care Services.
Specialist	CoPay: $45.00 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: $50.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: You pay a copayment for each 30 day supply, after deductible. Up to a 30-day supply at a Participating Pharmacy or up to a 90-day supply at a Designated 90-day Retail Pharmacy. Refer to the prescription drug list for more information.
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 49.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Up to a 30-day supply at a Participating Pharmacy or up to a 90-day supply at a Designated 90-day Retail Pharmacy. Refer to the prescription drug list for more information.
Generic Drugs	CoPay: $3.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: You pay a copayment for each 30 day supply. 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 a Participating Pharmacy, or up to a 90-day supply at a Designated 90-day Retail Pharmacy. 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 a Participating Pharmacy or up to a 30-day supply at a Designated 90-day Retail Pharmacy. Refer to the prescription drug list for more information.

Inpatient Coverage

Hospital Services	CoPay: $950.00 Copay per Day CoInsurance: Not Applicable Covered: Covered Benefit Explanation: The per day inpatient copayment will apply for a maximum of 4 day(s).
Inpatient Services	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $750.00 CoInsurance: 40.00% Coinsurance after deductible 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: $45.00 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: $950.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: The per day inpatient copayment will apply for a maximum of 4 day(s).
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 40.00% 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
Benefit Explanation: Children up to age 19, through the end of their birth month.

Major Dental Care

Routine Dental Checkups for Children

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.