Connect Bronze 0/4900 Indiv Medical/Rx Deductible – EPO
Network type: EPO
Coverage tier: Expanded Bronze
Primary care visit: $50 copay
Specialist visit: $110 copay
Urgent care visit: $50 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | Success
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| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | $50 copay |
| Specialist visit | $110 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | $1500 copay |
| Ambulance | 50% coinsurance |
| Hospital stay (facility) | $2,500 copay per Day |
| Hospital stay (physician) | 50% coinsurance |
| Outpatient procedure (facility) | 50% coinsurance |
| Outpatient procedure (physician) | 50% coinsurance |
| Physical rehabilitation | 50% coinsurance |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | $2500 copay |
Pharmacy, Drugs, and Medication
| Generic | $3 copay |
| Brand | $200 copay |
| Non-preferred Brand | 50% coinsurance after deductible |
| Specialty | 50% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 50% coinsurance |
| Imaging (CT/PET/MRI) | 50% coinsurance |
| Blood work | $75 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 50% coinsurance |
| Psychiatric hospital stay | $2,500 copay per Day |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/wBmrkf8zRm7cfNjtVbSVHrbV.pdf |
| Drug and medication plan formulary | https://www.cigna.com/individuals-families/member-guide/individuals-families-drug-list?consumerID=cigna&indicator=IFP&pdlYearType=CD |
| Search doctor list | https://www.cigna.com/ifp-providers |
