Connect Bronze 5500 Indiv Med Deductible Enhanced Diabetes Care – EPO
Network type: EPO
Coverage tier: Expanded Bronze
Primary care visit: $50 copay
Specialist visit: $90 copay
Urgent care visit: $75 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | Success
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| Out-of-pocket max | N/A per person N/A per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | $50 copay |
| Specialist visit | $90 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $75 copay |
| Emergency room | 40% after deductible |
| Ambulance | 40% after deductible |
| Hospital stay (facility) | 40% after deductible |
| Hospital stay (physician) | 40% after deductible |
| Outpatient procedure (facility) | 40% after deductible |
| Outpatient procedure (physician) | 40% after deductible |
| Physical rehabilitation | 40% after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 40% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $3 copay |
| Brand | 40% after deductible |
| Non-preferred Brand | 50% after deductible |
| Specialty | 50% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 40% after deductible |
| Imaging (CT/PET/MRI) | 40% after deductible |
| Blood work | 40% after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 40% after deductible |
| Psychiatric hospital stay | 40% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.cigna.com/static/www-cigna-com/docs/ifp/m-24-sbc-va-944886-b-connect5500diabetes-off.pdf |
| Drug and medication plan formulary | https://www.cigna.com/ifp-drug-lists |
| Search doctor list | https://www.cigna.com/ifp-providers |
