Cigna Connect 0
15105GA0020017
Expanded Bronze
HMO
Cigna Connect 0 is an Expanded Bronze HMO plan by Cigna Healthcare.
IMPORTANT: You are viewing the 2023 version of Cigna Connect 0 15105GA0020017. You can enroll in this plan if you qualify for special enrollment until the end of 2023.
Locations
Cigna Connect 0 is offered in the following counties.
Plan Overview
This is a plan overview for 2023 version of Cigna Connect 0 15105GA0020017.
| Insurer: | Cigna Healthcare |
| Network Type: | HMO |
| Metal Type: | Expanded Bronze |
| HSA Eligible?: | No |
| Plan ID: | 15105GA0020017 |
Cost-Sharing Overview
Cigna Connect 0 offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for Cigna Connect 0 includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $9,100.00 | $9100 per person | $18200 per group |
| Deductible: | $0.00 (medical only) | $0 per person (medical only) | $0 per group (medical only) |
| Coinsurance: | 50.00% (medical only) | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for Cigna Connect 0 will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | Not Applicable | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | Not Applicable | per person not applicable | per group not applicable |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | $0.00 |
| Copayment: | $5,300.00 |
| Coinsurance: | $2,200.00 |
| Limit: | $60.00 |
| Deductible: | $0.00 |
| Copayment: | $1,200.00 |
| Coinsurance: | $400.00 |
| Limit: | $20.00 |
| Deductible: | $0.00 |
| Copayment: | $700.00 |
| Coinsurance: | $900.00 |
| Limit: | $0.00 |
Notes:
- Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
- You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Cigna Connect 0?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904
Plan Features
Cigna Connect 0 offers the following features and referral requirements.
| Wellness Program: | No |
| Disease Program: | Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy |
| Notice Pregnancy: | No |
| Referral Specialist: | No |
| Specialist Requiring Referral: | |
| Plan Exclusions: | |
| Child Only Option?: | Allows Adult and Child-Only |
Network Details
The following network details will help you understand what Cigna Connect 0 covers when you are out of the service area or out of the country.
| Out of Country Coverage: | Yes |
| Out of Country Coverage Description: | Emergency Services Only |
| Out of Service Area Coverage: | Yes |
| Out of Service Area Coverage Description: | Emergency Services Only |
| National Network: | No |
Additional Benefits and Cost-Sharing
Cigna Connect 0 includes the following benefits at the cost sharing rates listed below.
| Service | In-Network Copay / Coinsurance | Out-of-Network Copay / Coinsurance | Limits and Explanation |
|---|---|---|---|
| Primary Care Visit to Treat an Injury or Illness Covered | $50.00 | 100.00% | Includes Mental Health Office Visits and Substance Use Disorder Office Visits. Refer to the policy for more information about Virtual Care Services. |
| Specialist Visit Covered | $115.00 | 100.00% | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $115.00 | 100.00% | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | 50.00% | 100.00% | |
| Outpatient Surgery Physician/Surgical Services Covered | 50.00% | 100.00% | |
| Hospice Services Covered | 50.00% | 100.00% | Life Expectancy of 18 months or less. Excludes Respite Care. |
| Routine Dental Services (Adult) | |||
| Infertility Treatment | |||
| Long-Term/Custodial Nursing Home Care | |||
| Private-Duty Nursing | |||
| Routine Eye Exam (Adult) | |||
| Urgent Care Centers or Facilities Covered | $75.00 | $75.00 | Out-of-network: You pay the same level as In-network if it is an emergency as defined in your plan, otherwise Not covered. |
| Home Health Care Services Covered | 50.00% | 100.00% | 120 Visit(s) per Year |
| Emergency Room Services Covered | $1,300.00 | $1,300.00 | Out-of-network: You pay the same level as In-network if it is an emergency as defined in your plan, otherwise Not covered. |
| Emergency Transportation/Ambulance Covered | 50.00% | 50.00% | Out-of-network: You pay the same level as In-network if it is an emergency as defined in your plan, otherwise Not covered. Coverage for Medically Necessary transport to the nearest facility capable of handling the Emergency Medical Condition. |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | $2400.00 Copay per Day | 100.00% | The per day inpatient copayment will apply for a maximum of four (4) days. |
| Inpatient Physician and Surgical Services Covered | 50.00% | 100.00% | |
| Bariatric Surgery | |||
| Cosmetic Surgery Not Covered | |||
| Skilled Nursing Facility Covered | 50.00% | 100.00% | 60 Days per Year |
| Prenatal and Postnatal Care Covered | 50.00% | 100.00% | |
| Delivery and All Inpatient Services for Maternity Care Covered | 50.00% | 100.00% | The per day inpatient copayment will apply for a maximum of four (4) days. |
| Mental/Behavioral Health Outpatient Services Covered | 50.00% | 100.00% | This benefit applies to all other Outpatient Services excluding Office Visits. Mental Health Office Visits are covered at the Primary care doctor visit copayment. Please refer to the SBC for more information. |
| Mental/Behavioral Health Inpatient Services Covered | $2400.00 Copay per Day | 100.00% | The per day inpatient copayment will apply for a maximum of four (4) days. |
| Substance Abuse Disorder Outpatient Services Covered | 50.00% | 100.00% | This benefit applies to all other Outpatient Services excluding Office Visits. Mental Health Office Visits are covered at the Primary care doctor visit copayment. Please refer to the SBC for more information. |
| Substance Abuse Disorder Inpatient Services Covered | $2400.00 Copay per Day | 100.00% | The per day inpatient copayment will apply for a maximum of four (4) days. |
| Generic Drugs Covered | $5.00 | 100.00% | 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 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. |
| Preferred Brand Drugs Covered | $250.00 | 100.00% | 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. |
| Non-Preferred Brand Drugs Covered | 50.00% Coinsurance after deductible | 100.00% | Up to a 30-day supply at any Participating Pharmacy or up to a 90-day supply at a Designated 90 day Retail Pharmacy. |
| Specialty Drugs Covered | 50.00% Coinsurance after deductible | 100.00% | 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. |
| Outpatient Rehabilitation Services Covered | 50.00% | 100.00% | 40 Visit(s) per Year Physical Therapy, Occupational Therapy, Speech Therapy, Audiology, Cognitive Rehabilitation, Spinal Manipulations/Adjustments (Chiropractic Care) Maximum does not apply to services for treatment of Autism Spectrum Disorders. Limited to a combined maximum of 40 visits per calendar year. |
| Habilitation Services Covered | 50.00% | 100.00% | 40 Visit(s) per Year Physical Therapy, Occupational Therapy, Speech Therapy Maximum does not apply to services for treatment of Autism Spectrum Disorders. Limited to a combined maximum of 40 visits per calendar year. |
| Chiropractic Care Covered | 50.00% | 100.00% | 40 Visit(s) per Year Physical Therapy, Occupational Therapy, Speech Therapy, Audiology, Cognitive Rehabilitation, Spinal Manipulations/Adjustments (Chiropractic Care) Maximum does not apply to services for treatment of Autism Spectrum Disorders. Limited to a combined maximum of 40 visits per calendar year. |
| Durable Medical Equipment Covered | 50.00% | 100.00% | Includes orthotics used to support, align, prevent or correct deformities. |
| Hearing Aids | |||
| Imaging (CT/PET Scans, MRIs) Covered | 50.00% | 100.00% | |
| Preventive Care/Screening/Immunization Covered | No Charge | 100.00% | Routine physicals and other preventive services. MDLive Virtual Wellness is covered as Preventive Care. |
| Routine Foot Care | |||
| Acupuncture | |||
| Weight Loss Programs Not Covered | |||
| Routine Eye Exam for Children Covered | No Charge | 100.00% | 1 Exam(s) per Year |
| Eye Glasses for Children Covered | No Charge | 100.00% | 1 Item(s) per Year |
| Dental Check-Up for Children Not Covered | |||
| Rehabilitative Speech Therapy Covered | 50.00% | 100.00% | 40 Visit(s) per Year Physical Therapy, Occupational Therapy, Speech Therapy, Audiology, Cognitive Rehabilitation, Spinal Manipulations/Adjustments (Chiropractic Care) Maximum does not apply to services for treatment of Autism Spectrum Disorders. Limited to a combined maximum of 40 visits per calendar year. |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | 50.00% | 100.00% | 40 Visit(s) per Year Physical Therapy, Occupational Therapy, Speech Therapy, Audiology, Cognitive Rehabilitation, Spinal Manipulations/Adjustments (Chiropractic Care) Maximum does not apply to services for treatment of Autism Spectrum Disorders. Limited to a combined maximum of 40 visits per calendar year. |
| Well Baby Visits and Care Covered | No Charge | 100.00% | Care provided for birth through age 5. |
| Laboratory Outpatient and Professional Services Covered | $55.00 | 100.00% | Refer to the policy for more information regarding Diabetes. |
| X-rays and Diagnostic Imaging Covered | 50.00% | 100.00% | |
| Basic Dental Care – Child Not Covered | |||
| Orthodontia – Child Not Covered | |||
| Major Dental Care – Child Not Covered | |||
| Basic Dental Care – Adult | |||
| Orthodontia – Adult | |||
| Major Dental Care – Adult | |||
| Abortion for Which Public Funding is Prohibited | |||
| Transplant Covered | 50.00% | 100.00% | 10000 Dollars per Procedure LifeSource Travel and Lodging Benefit Maximum: $10,000 per Insured Person per transplant. |
| Accidental Dental Covered | 50.00% | 100.00% | Limited to: Treatment which begins within 90 days after the date of the dental injury; and the treatment is completed within 12 months after the date of the dental injury. |
| Dialysis Covered | 50.00% | 100.00% | Benefit depends on place of treatment. |
| Allergy Testing Covered | 50.00% | 100.00% | |
| Chemotherapy Covered | 50.00% | 100.00% | |
| Radiation Covered | 50.00% | 100.00% | |
| Diabetes Education Covered | No Charge | 100.00% | Including nutritional therapy. |
| Prosthetic Devices Covered | 50.00% | 100.00% | |
| Infusion Therapy Covered | 50.00% | 100.00% | Insulin infusion devices. |
| Treatment for Temporomandibular Joint Disorders Covered | 50.00% | 100.00% | |
| Nutritional Counseling Covered | 50.00% | 100.00% | 4 Visit(s) per Year Nutritional counseling for the treatment of obesity, which includes morbid obesity limited to 4 visits per year. Nutritional counseling for diabetics, unlimited. |
| Reconstructive Surgery Covered | 50.00% | 100.00% | Reconstructive Surgery to restore a bodily function or to correct a deformity caused by Injury or congenital defect of a Newborn child, or for Medically Necessary Reconstructive Surgery performed to restore symmetry incident to a mastectomy or lumpectomy. |
| Gender Affirming Care | |||
| Tier 2 Generic Drugs Covered | $35.00 | 100.00% | 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. |
Free Preventive Services
There is no copayment or coinsurance for any of the following Cigna Connect 0 preventive services. This is true even if you haven’t met your yearly deductible.
Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for Cigna Connect 0 including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.
| Summary of Benefits: | Summary of Benefits Link |
| Plan Brochure: | Plan Brochure Link |
| Formulary: | Formulary Link |
| Premium Payment Website: | Premium Payment Link |
Ready to sign up for Cigna Connect 0?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904