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: $75.00
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: $70.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: 30 day supply at any participating pharmacy or up to a 90 day supply at a 90 day retail pharmacy. After deductible, you pay a copayment for each 30 day supply. 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: 50.00% 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. After deductible, you pay a copayment for each 30 day supply. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30 day supply.
Generic Drugs
CoPay: $3.00
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. 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.
Specialty Drugs
CoPay: Not Applicable
CoInsurance: 50.00% 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: 40.00% 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: 40.00% Coinsurance after deductible
Covered: Covered
Emergency and Urgent Care
Emergency Room
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Urgent Care Facility
CoPay: $35.00
CoInsurance: Not Applicable
Covered: Covered
Maternity
Labor and Delivery Hospital Stay
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
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
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.
Nondiscrimination Link"
1-817-813-4562, TTY 711
