Connect Bronze 8900 Indiv Med Deductible - 97667AZ0110016 Health Insurance Plan
Cigna HealthCare of Arizona, Inc health insurance plan with the Plan ID 97667AZ0110016. The plan is called Connect Bronze 8900 Indiv Med Deductible.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 64.91% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.09% of the costs of all covered benefits (according to the Issuer).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 65.60% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 34.40% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
| Health Insurance Plan ID | 97667AZ0110016 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Arizona | ||||||||||||||||||
| Health Insurance Issuer | Cigna HealthCare of Arizona, Inc | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 97667AZ0110016-01 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 97667AZ0110016-00 Standard On Exchange Plan - 97667AZ0110016-01 |
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| Last Plan Update Date | Sat, 16 Dec 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Connect Bronze 8900 Indiv Med Deductible Health Insurance Plan, 97667AZ0110016-01
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | No Charge after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | No Charge after deductible |
100.00% |
| Bariatric Surgery
Benefit depends on type of service provided. |
YES | No Charge after deductible |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | No Charge after deductible |
100.00% |
| Chiropractic Care
Maximum of 20 visits per calendar year. |
YES | No Charge after deductible |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
The per day inpatient copayment will apply for a maximum of five (5) days. |
YES | $1,500.00 |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | No Charge |
100.00% |
| Dialysis
Benefit depends on place of treatment. |
YES | No Charge after deductible |
100.00% |
| Durable Medical Equipment
|
YES | No Charge after deductible |
100.00% |
| Emergency Room Services
Out-of-Network: You pay the same level as In-network if it is an emergency as defined in your plan, otherwise Not covered. |
YES | No Charge after deductible |
No Charge after deductible |
| Emergency Transportation/Ambulance
Out-of-Network: You pay the same level as In-network if it is an emergency as defined in your plan, otherwise Not covered. |
YES | No Charge after deductible |
No Charge after deductible |
| Eye Glasses for Children
Children up to age 19. Limit 1 pair of glasses (lenses and frames from pediatric selection) per 12 month period. One pair of contact lenses - in lieu of lenses and frames benefit, (may not receive contact lenses and frames in same benefit year). |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
You pay a copayment for each 30 day supply. Cost sharing shown applies to Tier 1-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 2-Generic Drugs, which may apply a higher cost share. Limited to a 30-day supply at a Participating Pharmacy or up to a 90-day supply at a Designated 90-day Pharmacy. Formulary Diabetic Supplies are covered at no charge. Refer to the prescription drug list for more information. |
YES | $15.00 |
100.00% |
| Habilitation Services
Maximum of 60 visits per calendar year, combined with Physical, Occupational and Speech Therapies, Cardiac & Pulmonary Rehabilitation. Maximums for Rehabilitative services do not reduce maximums for Habilitative Services. |
YES | No Charge after deductible |
100.00% |
| Hearing Aids
Maximum of 1 hearing aid per ear, per calendar year. |
YES | No Charge after deductible |
100.00% |
| Home Health Care Services
Limit: 42.0 Visit(s) per Year |
YES | No Charge after deductible |
100.00% |
| Hospice Services
|
YES | No Charge after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | No Charge after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | No Charge after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
The per day inpatient copayment will apply for a maximum of five (5) days. |
YES | $1,500.00 Copay per Day |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | No Charge after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
Refer to the policy for more information regarding Diabetes. |
YES | No Charge after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
The per day inpatient copayment will apply for a maximum of five (5) days. |
YES | $1,500.00 Copay per Day |
100.00% |
| Mental/Behavioral Health Outpatient Services
This benefit applies to all other Outpatient Services excluding Office Visits. Mental Health Office Visits are covered at the Primary care doctor visit copayment. Please refer to the SBC for more information. |
YES | No Charge after deductible |
100.00% |
| Non-Preferred Brand Drugs
Limited to a 30-day supply at a Participating Pharmacy or up to a 90-day supply at a Designated 90-day Pharmacy. |
YES | No Charge after deductible |
100.00% |
| Nutritional Counseling
|
YES | No Charge after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Benefit depends on type of service provided and licensure. |
YES | $75.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | No Charge after deductible |
100.00% |
| Outpatient Rehabilitation Services
Maximum of 60 visits per calendar year, combined with Physical, Occupational, Speech Therapies, Cardiac & Pulmonary Rehabilitation. Maximums for Habilitative Services do not reduce maximums for Rehabilitative Services. |
YES | No Charge after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | No Charge after deductible |
100.00% |
| Preferred Brand Drugs
Limited to a 30-day supply at any Participating Pharmacy or up to a 90-day supply at a Designated 90 day Retail Pharmacy. Formulary Diabetic Supplies are covered at no charge. Refer to the prescription drug list for more information. |
YES | No Charge after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge after deductible |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Includes Mental Health Office Visits and Substance Use Disorder Office Visits. Refer to the policy for more information about Virtual Care Services. |
YES | $60.00 |
100.00% |
| Private-Duty Nursing
If determined to be medically necessary; as part of inpatient hospital care coverage. |
YES | No Charge after deductible |
100.00% |
| Prosthetic Devices
|
YES | No Charge after deductible |
100.00% |
| Radiation
|
YES | No Charge after deductible |
100.00% |
| Reconstructive Surgery
|
YES | No Charge after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Maximum of 60 visits per calendar year, combined with Physical, Occupational, Speech Therapies, Cardiac & Pulmonary Rehabilitation. Maximums for Habilitative Services do not reduce maximums for rehabilitative services. |
YES | No Charge after deductible |
100.00% |
| Rehabilitative Speech Therapy
Maximum of 60 visits per calendar year, combined with Physical, Occupational, Speech Therapies, Cardiac & Pulmonary Rehabilitation. Maximums for Habilitative Services do not reduce maximums for rehabilitative services. |
YES | No Charge after deductible |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year Children up to age 19. |
YES | No Charge |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Maximum of 90 days per calendar year. |
YES | No Charge after deductible |
100.00% |
| Specialist Visit
|
YES | $75.00 |
100.00% |
| Specialty Drugs
Including other high cost drugs. Limited to a 30-day supply at a Participating Pharmacy or up to a 30-day supply at a Designated 90-day Pharmacy. |
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
The per day inpatient copayment will apply for a maximum of five (5) days. |
YES | $1,500.00 Copay per Day |
100.00% |
| Substance Abuse Disorder Outpatient Services
This benefit applies to all other Outpatient Services excluding Office Visits. Mental Health Office Visits are covered at the Primary care doctor visit copayment. Please refer to the SBC for more information. |
YES | No Charge after deductible |
100.00% |
| Tier 2 - Generic Drugs
LImited to a 30 day supply at any Designated pharmacy, or up to a 90 day supply at any pharmacy. |
YES | No Charge after deductible |
100.00% |
| Transplant
LifeSource Facility Travel Maximum: $10,000 per insured person, per transplant. See policy for additional information on Cigna LifeSOURCE Designated Transplant Network Facility. |
YES | No Charge after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | No Charge after deductible |
100.00% |
| Urgent Care Centers or Facilities
Out-of-Network: You pay the same level as In-network if it is an emergency as defined in your plan, otherwise Not covered. |
YES | $110.00 |
$110.00 |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | No Charge after deductible |
100.00% |
Connect Bronze 8900 Indiv Med Deductible Health Insurance Plan Variant 97667AZ0110016-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.656027708813546 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Bronze On Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | AZF003 |
| Formulary URL | URL |
| HIOS Product ID | 97667AZ011 |
| Import Date | 2023-12-16 01:02:09 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 5 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 64.91% |
| Issuer ID | 97667 |
| Issuer Marketplace Marketing Name | Cigna HealthCare of Arizona, Inc |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Expanded Bronze |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | AZN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Services Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency Services Only |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 97667AZ0110016-01 |
| Plan Marketing Name | Connect Bronze 8900 Indiv Med Deductible |
| Plan Type | HMO |
| Plan Variant Marketing Name | Connect Bronze 8900 Indiv Med Deductible |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $3,000 |
| SBC Scenario, Having a Baby, Deductible | $5,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $900 |
| SBC Scenario, Having Diabetes, Deductible | $1,300 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,100 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | AZS001 |
| Source Name | HIOS |
| Plan ID | 97667AZ0110016 |
| State Code | AZ |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $17800 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $8900 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $8,900 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $17800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8900 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,900 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | Yes |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Connect Bronze 8900 Indiv Med Deductible Health Insurance Plan, 97667AZ0110016
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Connect Bronze 8900 Indiv Med Deductible, 97667AZ0110016 Health Insurance Plan, 97667AZ0110016
-
Does Connect Bronze 8900 Indiv Med Deductible Health Insurance Plan, 97667AZ0110016 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (97667AZ0110016) Health Insurance Plan, Variant (97667AZ0110016-01) offer Disease Management Programs?
Does (97667AZ0110016) Health Insurance Plan, Variant (97667AZ0110016-01) have Out Of Country Coverage?
Does (97667AZ0110016) Health Insurance Plan, Variant (97667AZ0110016-01) have Out of Service Area Coverage?
Does (97667AZ0110016) Health Insurance Plan, Variant (97667AZ0110016-01) offer Disease Management Programs?
Does Connect Bronze 8900 Indiv Med Deductible Health Insurance Plan, Variant (97667AZ0110016-01) offer Disease Management Programs for Asthma?
Does Connect Bronze 8900 Indiv Med Deductible Health Insurance Plan, Variant (97667AZ0110016-01) offer Disease Management Programs for Heart disease?
Does Connect Bronze 8900 Indiv Med Deductible Health Insurance Plan, Variant (97667AZ0110016-01) offer Disease Management Programs for Diabetes?
Does Connect Bronze 8900 Indiv Med Deductible Health Insurance Plan, Variant (97667AZ0110016-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Connect Bronze 8900 Indiv Med Deductible Health Insurance Plan, Variant (97667AZ0110016-01) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Thu, 21 Nov 2024 00:44 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API