Connect Gold 3500 Indiv Med Deductible Enhanced Diabetes Care – 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	$7,750 per person $15,500 per family
Metal tier	Gold

Visit Copay

Primary care visit	$5 copay
Specialist visit	$35 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$30 copay
Emergency room	35% coinsurance after deductible
Ambulance	15% coinsurance after deductible
Hospital stay (facility)	15% coinsurance after deductible
Hospital stay (physician)	15% coinsurance after deductible
Outpatient procedure (facility)	15% after deductible
Outpatient procedure (physician)	15% coinsurance after deductible
Physical rehabilitation	15% coinsurance after deductible

Maternitowny and Pregnancy

Labor, delivery, hospital stay

15% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	No charge
Brand	$35 copay
Non-preferred Brand	50% coinsurance after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	15% coinsurance after deductible
Imaging (CT/PET/MRI)	15% coinsurance after deductible
Blood work	15% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	15% coinsurance after deductible
Psychiatric hospital stay	15% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://d2ed110nmrd591.cloudfront.net/blobs/tSQhZ3sfc4mSfDXa8LHg8axV.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