Connect Silver 8500 Indiv Med Deductible - 73033SC0010011 Health Insurance Plan
Cigna HealthCare of South Carolina, Inc. health insurance plan with the Plan ID 73033SC0010011. The plan is called Connect Silver 8500 Indiv Med Deductible.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 70.05% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 29.95% 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 70.22% (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 29.78% 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 | 73033SC0010011 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | South Carolina | ||||||||||||||||||
| Health Insurance Issuer | Cigna HealthCare of South Carolina, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 73033SC0010011-00 | ||||||||||||||||||
| 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 - 73033SC0010011-00 Standard On Exchange Plan - 73033SC0010011-01 Open to Indians below 300% FPL - 73033SC0010011-02 Open to Indians above 300% FPL - 73033SC0010011-03 73% AV Silver Plan - 73033SC0010011-04 |
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| Last Plan Update Date | Fri, 03 Nov 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Connect Silver 8500 Indiv Med Deductible Health Insurance Plan, 73033SC0010011-00
| 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
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | No Charge after deductible |
100.00% |
| Chiropractic Care
Limited to 30 visits per year. |
YES | No Charge after deductible |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | No Charge after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
Routine Foot Care and Nutritional Counseling covered based on Medical Necessity. |
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
Limited to 1 pair of glasses (lenses and frames from pediatric selection) per 12 month period. |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
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. Up to a 30 day supply at any Participating Pharmacy, or up to a 90 day supply at any Designated 90 day retail pharmacy. 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 | $5.00 |
100.00% |
| Habilitation Services
Physical Therapy, Occupational Therapy, Speech Therapy limited to 30 combined visits per year. |
YES | No Charge after deductible |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 60.0 Visit(s) per Year |
YES | No Charge after deductible |
100.00% |
| Hospice Services
Limit: 6.0 Months per Episode |
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)
|
YES | No Charge after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | No Charge after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
You pay a copayment/diagnostic test; deductible does not apply for laboratory 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
|
YES | No Charge after deductible |
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
Up to a 30-day supply at any Participating Pharmacy or up to a 90-day supply at a Designated 90 day Retail Pharmacy. |
YES | No Charge after deductible |
100.00% |
| Nutritional Counseling
|
NO | ||
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $65.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | No Charge after deductible |
100.00% |
| Outpatient Rehabilitation Services
Cardiac and Pulmonary Rehabilitation Therapy unlimited visits. Physical Therapy, Occupational Therapy, Speech Therapy limited to 30 combined visits per year |
YES | No Charge after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | No Charge after deductible |
100.00% |
| Preferred Brand Drugs
Up to a 30-day supply at any Participating Pharmacy or up to a 90-day supply at a Designated 90 day Retail Pharmacy. 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 | $120.00 |
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 | $40.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| 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
Physical Therapy, Occupational Therapy, Speech Therapy limited to 30 combined visits per year. |
YES | No Charge after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year |
YES | No Charge after deductible |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limited to 1 visit per 12 month period. |
YES | No Charge |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 60.0 Days per Year |
YES | No Charge after deductible |
100.00% |
| Specialist Visit
|
YES | $65.00 |
100.00% |
| Specialty Drugs
Including other high cost drugs. Up to a 30-day supply at any Participating Pharmacy or up to a 30-day supply at a Designated 90 day Retail Pharmacy. |
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | No Charge after deductible |
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
You pay a copayment for each 30-day supply. Up to a 30-day supply at any participating pharmacy or up to a 90-day supply at a Designated 90-day Pharmacy |
YES | $25.00 |
100.00% |
| Transplant
Travel expenses are $10,000 per insured person, per lifetime. 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 | $65.00 |
$65.00 |
| 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 Silver 8500 Indiv Med Deductible Health Insurance Plan Variant 73033SC0010011-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7021783695375401 |
| 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 |
| 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 | SCF007 |
| Formulary URL | URL |
| HIOS Product ID | 73033SC001 |
| Import Date | 2023-11-03 01:01:53 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 70.05% |
| Issuer ID | 73033 |
| Issuer Marketplace Marketing Name | Cigna Healthcare of South Carolina |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Silver |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | SCN001 |
| 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) | 73033SC0010011-00 |
| Plan Marketing Name | Connect Silver 8500 Indiv Med Deductible |
| Plan Type | HMO |
| Plan Variant Marketing Name | Connect Silver 8500 Indiv Med Deductible |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $8,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $900 |
| SBC Scenario, Having Diabetes, Deductible | $900 |
| 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 | SCS001 |
| Source Name | HIOS |
| Plan ID | 73033SC0010011 |
| State Code | SC |
| 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 | $17000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $8500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $8,500 |
| 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 | $17000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8500 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,500 |
| 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 8500 Indiv Med Deductible Health Insurance Plan, 73033SC0010011
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Connect Silver 8500 Indiv Med Deductible, 73033SC0010011 Health Insurance Plan, 73033SC0010011
-
Does Connect Silver 8500 Indiv Med Deductible Health Insurance Plan, 73033SC0010011 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (73033SC0010011) Health Insurance Plan, Variant (73033SC0010011-00) offer Disease Management Programs?
Does (73033SC0010011) Health Insurance Plan, Variant (73033SC0010011-00) have Out Of Country Coverage?
Does (73033SC0010011) Health Insurance Plan, Variant (73033SC0010011-00) have Out of Service Area Coverage?
Does (73033SC0010011) Health Insurance Plan, Variant (73033SC0010011-00) offer Disease Management Programs?
Does Connect Silver 8500 Indiv Med Deductible Health Insurance Plan, Variant (73033SC0010011-00) offer Disease Management Programs for Asthma?
Does Connect Silver 8500 Indiv Med Deductible Health Insurance Plan, Variant (73033SC0010011-00) offer Disease Management Programs for Heart disease?
Does Connect Silver 8500 Indiv Med Deductible Health Insurance Plan, Variant (73033SC0010011-00) offer Disease Management Programs for Diabetes?
Does Connect Silver 8500 Indiv Med Deductible Health Insurance Plan, Variant (73033SC0010011-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Connect Silver 8500 Indiv Med Deductible Health Insurance Plan, Variant (73033SC0010011-00) 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