Connect Gold 2500 Indiv Med Deductible – EPO

Description

Health Care Plan Details

Network type	EPO
Deductible	Success Your progress has been saved. We have sent an email to with a link to continue your application ×
Out-of-pocket max	$8,500 per person $17,000 per family
Metal tier	Gold

Visit Copay

Primary care visit	No charge
Specialist visit	$50 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$30 copay
Emergency room	20% coinsurance after deductible
Ambulance	20% coinsurance after deductible
Hospital stay (facility)	20% coinsurance after deductible
Hospital stay (physician)	20% coinsurance after deductible
Outpatient procedure (facility)	20% after deductible
Outpatient procedure (physician)	20% coinsurance after deductible
Physical rehabilitation	20% coinsurance after deductible

Maternitowny and Pregnancy

Labor, delivery, hospital stay

20% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	No charge
Brand	$80 copay
Non-preferred Brand	50% coinsurance after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	20% coinsurance after deductible
Imaging (CT/PET/MRI)	20% coinsurance after deductible
Blood work	20% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	20% coinsurance after deductible
Psychiatric hospital stay	20% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://d2ed110nmrd591.cloudfront.net/blobs/HnwghGSx1hayYoPq673HNkkF.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