Connect Silver 0 Indiv Med Deductible - 97667AZ0110031 Health Insurance Plan
Cigna HealthCare of Arizona, Inc health insurance plan with the Plan ID 97667AZ0110031. The plan is called Connect Silver 0 Indiv Med Deductible.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 70.25% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 29.75% 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 74.45% (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 25.55% 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 | 97667AZ0110031 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 97667AZ0110031-00 | ||||||||||||||||||
| 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 - 97667AZ0110031-00 Standard On Exchange Plan - 97667AZ0110031-01 Open to Indians below 300% FPL - 97667AZ0110031-02 Open to Indians above 300% FPL - 97667AZ0110031-03 73% AV Silver Plan - 97667AZ0110031-04 |
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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 Silver 0 Indiv Med Deductible Health Insurance Plan, 97667AZ0110031-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 50.00% |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 50.00% |
100.00% |
| Bariatric Surgery
Benefit depends on type of service provided. |
YES | 50.00% |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 50.00% |
100.00% |
| Chiropractic Care
Maximum of 20 visits per calendar year. |
YES | 50.00% |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
The per day inpatient copayment will apply for a maximum of two or three (2 or 3) days. |
YES | $2,500.00 |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | No Charge |
100.00% |
| Dialysis
Benefit depends on place of treatment. |
YES | 50.00% |
100.00% |
| Durable Medical Equipment
|
YES | 35.00% |
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 | $1,200.00 |
$1,200.00 |
| 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 | 50.00% |
50.00% |
| 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 | $5.00 |
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 | 35.00% |
100.00% |
| Hearing Aids
Maximum of 1 hearing aid per ear, per calendar year. |
YES | 50.00% |
100.00% |
| Home Health Care Services
Limit: 42.0 Visit(s) per Year |
YES | No Charge |
100.00% |
| Hospice Services
|
YES | 50.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 50.00% |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 50.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
The per day inpatient copayment will apply for a maximum of two or three (2 or 3) days. |
YES | $2,500.00 Copay per Day |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 50.00% |
100.00% |
| Laboratory Outpatient and Professional Services
Refer to the policy for more information regarding Diabetes. |
YES | $65.00 |
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 two or three (2 or 3) days. |
YES | $2,500.00 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 | 50.00% |
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 | 50.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
|
YES | 50.00% |
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 | $95.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 50.00% |
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 | 35.00% |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 50.00% |
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. After deductible, you pay a copayment for each 30 day supply. Formulary Diabetic Supplies are covered at no charge. Refer to the prescription drug list for more information. |
YES | $125.00 Copay after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | 50.00% |
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 | $55.00 |
100.00% |
| Private-Duty Nursing
If determined to be medically necessary; as part of inpatient hospital care coverage. |
YES | 50.00% |
100.00% |
| Prosthetic Devices
|
YES | 50.00% |
100.00% |
| Radiation
|
YES | 50.00% |
100.00% |
| Reconstructive Surgery
|
YES | 50.00% |
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 | 35.00% |
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 | 35.00% |
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 | 50.00% |
100.00% |
| Specialist Visit
|
YES | $95.00 |
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 | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
The per day inpatient copayment will apply for a maximum of two or three (2 or 3) days. |
YES | $2,500.00 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 | 50.00% |
100.00% |
| Tier 2 - Generic Drugs
You pay a copayment for each 30 day supply. Limited to a 30-day supply at any participating pharmacy or up to a 90-day supply at a Designated 90-day Pharmacy |
YES | $30.00 |
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 |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 50.00% |
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 | $70.00 |
$70.00 |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 50.00% |
100.00% |
Connect Silver 0 Indiv Med Deductible Health Insurance Plan Variant 97667AZ0110031-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.744464210911019 |
| 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 Silver Off Exchange Plan |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $8000 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $4000 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $4,000 |
| Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| 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 | AZF009 |
| 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 | 3 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 70.25% |
| Issuer ID | 97667 |
| Issuer Marketplace Marketing Name | Cigna HealthCare of Arizona, Inc |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | No |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $0 |
| Medical EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Metal Level | Silver |
| 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) | 97667AZ0110031-00 |
| Plan Marketing Name | Connect Silver 0 Indiv Med Deductible |
| Plan Type | HMO |
| Plan Variant Marketing Name | Connect Silver 0 Indiv Med Deductible |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,200 |
| SBC Scenario, Having a Baby, Copayment | $5,600 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $300 |
| SBC Scenario, Having Diabetes, Copayment | $1,200 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $800 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $600 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | AZS001 |
| Source Name | HIOS |
| Plan ID | 97667AZ0110031 |
| 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 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $18800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9400 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,400 |
| 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 Silver 0 Indiv Med Deductible Health Insurance Plan, 97667AZ0110031
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Connect Silver 0 Indiv Med Deductible, 97667AZ0110031 Health Insurance Plan, 97667AZ0110031
-
Does Connect Silver 0 Indiv Med Deductible Health Insurance Plan, 97667AZ0110031 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (97667AZ0110031) Health Insurance Plan, Variant (97667AZ0110031-00) offer Disease Management Programs?
Does (97667AZ0110031) Health Insurance Plan, Variant (97667AZ0110031-00) have Out Of Country Coverage?
Does (97667AZ0110031) Health Insurance Plan, Variant (97667AZ0110031-00) have Out of Service Area Coverage?
Does (97667AZ0110031) Health Insurance Plan, Variant (97667AZ0110031-00) offer Disease Management Programs?
Does Connect Silver 0 Indiv Med Deductible Health Insurance Plan, Variant (97667AZ0110031-00) offer Disease Management Programs for Asthma?
Does Connect Silver 0 Indiv Med Deductible Health Insurance Plan, Variant (97667AZ0110031-00) offer Disease Management Programs for Heart disease?
Does Connect Silver 0 Indiv Med Deductible Health Insurance Plan, Variant (97667AZ0110031-00) offer Disease Management Programs for Diabetes?
Does Connect Silver 0 Indiv Med Deductible Health Insurance Plan, Variant (97667AZ0110031-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Connect Silver 0 Indiv Med Deductible Health Insurance Plan, Variant (97667AZ0110031-00) 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