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Connect Bronze 4500 Indiv Med Deductible Enhanced Diabetes Care

73033SC0010005
Expanded Bronze
HMO

Connect Bronze 4500 Indiv Med Deductible Enhanced Diabetes Care is an Expanded Bronze HMO plan by Cigna Healthcare of South Carolina.

IMPORTANT: You are viewing the 2024 version of Connect Bronze 4500 Indiv Med Deductible Enhanced Diabetes Care 73033SC0010005. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

Connect Bronze 4500 Indiv Med Deductible Enhanced Diabetes Care is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of Connect Bronze 4500 Indiv Med Deductible Enhanced Diabetes Care 73033SC0010005.
Insurer: Cigna Healthcare of South Carolina
Network Type: HMO
Metal Type: Expanded Bronze
HSA Eligible?: No
Plan ID: 73033SC0010005

Cost-Sharing Overview

Connect Bronze 4500 Indiv Med Deductible Enhanced Diabetes Care offers the following cost-sharing.

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 Connect Bronze 4500 Indiv Med Deductible Enhanced Diabetes Care?

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

Connect Bronze 4500 Indiv Med Deductible Enhanced Diabetes Care 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 Connect Bronze 4500 Indiv Med Deductible Enhanced Diabetes Care 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

Connect Bronze 4500 Indiv Med Deductible Enhanced Diabetes Care 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 Not ApplicableNot Applicable 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
$90.00 Not ApplicableNot Applicable 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$90.00 Not ApplicableNot Applicable 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Hospice Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%6.0 Months per Episode
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 Not Applicable$75.00 Not Applicable 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
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%60.0 Visit(s) per Year
Emergency Room Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible 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
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible Out-of-network: You pay the same level as In-network if it is an emergency as defined in your plan, otherwise Not covered.
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Inpatient Physician and Surgical Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Bariatric Surgery
Cosmetic Surgery
Skilled Nursing Facility
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%60.0 Days per Year
Prenatal and Postnatal Care
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Mental/Behavioral Health Outpatient Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 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
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Substance Abuse Disorder Outpatient Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 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
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Generic Drugs
Covered
$3.00 Not ApplicableNot Applicable 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 any 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.
Preferred Brand Drugs
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 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. Formulary Diabetic Supplies are covered at no charge. Refer to the prescription drug list for more information.
Non-Preferred Brand Drugs
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 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
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 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
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Cardiac and Pulmonary Rehabilitation Therapy unlimited visits. Physical Therapy, Occupational Therapy, Speech Therapy limited to 30 combined visits per year
Habilitation Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Physical Therapy, Occupational Therapy, Speech Therapy limited to 30 combined visits per year.
Chiropractic Care
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Limited to 30 visits per year.
Durable Medical Equipment
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Hearing Aids
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Preventive Care/Screening/Immunization
Covered
Not Applicable No ChargeNot Applicable 100.00%
Routine Foot Care
Acupuncture
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
Not Applicable No ChargeNot Applicable 100.00% Limited to 1 visit per 12 month period.
Eye Glasses for Children
Covered
Not Applicable No ChargeNot Applicable 100.00% Limited to 1 pair of glasses (lenses and frames from pediatric selection) per 12 month period.
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%30.0 Visit(s) per Year
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Physical Therapy, Occupational Therapy, Speech Therapy limited to 30 combined visits per year.
Well Baby Visits and Care
Covered
Not Applicable No ChargeNot Applicable 100.00%
Laboratory Outpatient and Professional Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Refer to the policy for more information regarding Diabetes.
X-rays and Diagnostic Imaging
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 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
Not Applicable No Charge after deductibleNot Applicable 100.00% Travel expenses are $10,000 per insured person, per lifetime. See policy for additional information on Cigna LifeSOURCE Designated Transplant Network Facility.
Accidental Dental
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Dialysis
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Benefit depends on place of treatment.
Allergy Testing
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Chemotherapy
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Radiation
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Diabetes Education
Covered
Not Applicable No ChargeNot Applicable 100.00% Routine Foot Care and Nutritional Counseling covered based on Medical Necessity.
Prosthetic Devices
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Infusion Therapy
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Nutritional Counseling
Not Covered
Reconstructive Surgery
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Gender Affirming Care
Tier-2 Generic Drugs
Covered
$35.00 Not ApplicableNot Applicable 100.00% You pay a copayment for each 30-day supply. Up to a 30-day supply at any participating pharmacy or up to a 90-day supply at a Designated 90-day Pharmacy

Free Preventive Services

There is no copayment or coinsurance for any of the following Connect Bronze 4500 Indiv Med Deductible Enhanced Diabetes Care 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.

Additional Resources

Below are additional resources for Connect Bronze 4500 Indiv Med Deductible Enhanced Diabetes Care 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 Connect Bronze 4500 Indiv Med Deductible Enhanced Diabetes Care?

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

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