myCigna Copay Assure Silver

Individual Health Insurance (Obamacare)

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Benefits & Coverage

Plan Name
myCigna Copay Assure Silver
Plan Year
2015
Insurance Type
Individual Health Insurance (Obamacare)
Insurance Provider
Metal Level
Silver
Out-of-Pocket Maximum
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness
$30 Copay
Specialist Visit
$60 Copay
Laboratory Outpatient and Professional Services
40% Coinsurance
X-rays and Diagnostic Imaging
40% Coinsurance
Diagnostic Imaging such as MRIs, CT, and PET scans
$750 Copay
Deductible - Family
$0
Out-of-Pocket Maximum - Family
$13200

Prescription drug coverage

Generic Drugs
$4 Copay
Preferred Brand Drugs
$60 Copay
Non-Preferred Brand Drugs
50% Coinsurance
Specialty Drugs
40% Coinsurance

Access to doctors and hospitals

Provider directory URL
http://www.Cigna.com/ifp-providers
Does this plan have access to a national provider network?
Yes
Is a referral required to see a Specialist?
Not Covered
Does this plan cover services outside plan service area?
Yes - All Services
Does this plan cover services outside the country?
Yes - Emergency Services Only

Hospital services

Emergency Room Services
$500 Copay
Inpatient Hospital Services (e.g., Hospital Stay)
$2500 Copay per Day
Inpatient Physician and Surgical Services
30% Coinsurance
Emergency Transportation or Ambulance Service
$500 Copay

Maternity

Prenatal and Postnatal Care
30% Coinsurance
Delivery and all inpatient services for maternity care
30% Coinsurance

Mental Health

Mental/Behavioral Health Outpatient Services
$60 Copay
Mental/Behavioral Health Inpatient Services
$2500 Copay
Substance use disorder outpatient services
$60 Copay
Substance use disorder inpatient services
$2500 Copay

Medical Management Programs

Does this plan offer a wellness program?
Not Covered

Vision Coverage

Routine Eye Exam for Children
Included
Eye Glasses for Children
Included
Routine Eye Exam for Adults
Not Covered

Child Dental Coverage

Child Dental Coverage - Routine Dental Care
Not Covered
Child Dental Coverage - Basic Dental Care
Not Covered
Child Dental Coverage - Orthodontia
Not Covered
Child Dental Coverage - Major Dental Care
Not Covered

Adult Dental Coverage

Adult Dental Coverage - Routine Dental Care
Not Covered
Adult Dental Coverage - Basic Dental Care
Not Covered
Adult Dental Coverage - Orthodontia
Not Covered
Adult Dental Coverage - Major Dental Care
Not Covered

Exclusions and Limitations

More Included Benefits
Other Practitioner Office Visit (Nurse, Physician Assistant)
Preventive Care/Screening/Immunization
Hearing Aids
Private-Duty Nursing
Imaging (CT/PET Scans, MRIs)
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Outpatient Surgery Physician/Surgical Services
Urgent Care Centers or Facilities
Inpatient Physician and Surgical Services
Outpatient Rehabilitation Services
Habilitation Services
Durable Medical Equipment
Hospice Services
Applied Behavior Analysis Based Therapies
Dental Anesthesia
Inherited Metabolic Disorder - PKU
Accidental Dental
Allergy Testing
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Nutritional Counseling
Prosthetic Devices
Radiation
Reconstructive Surgery
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
Transplant
Treatment for Temporomandibular Joint Disorders
Well Baby Visits and Care
Bone Marrow Testing
Clinical Trials
Newborn Services Other
Non-Preferred Generic Drugs
More Limited Benefits
Skilled Nursing Facility
Home Health Care Services
Chiropractic Care
More Excluded Benefits
Acupuncture
Bariatric Surgery
Cosmetic Surgery
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Weight Loss Programs
Dental Check-Up for Children
Routine Foot Care
Non-Emergency Care When Traveling Outside the U.S.
Abortion for Which Public Funding is Prohibited

What To Know

  • This is an ACA (Obamacare) compliant health plan.
  • This plan is eligible for a tax credit subsidy

Physician Directory

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