Cigna Connect 3500 - 81808UT0020003 Health Insurance Plan

Cigna Health and Life Insurance Company health insurance plan with the Plan ID 81808UT0020003. The plan is called Cigna Connect 3500.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 64.23% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.77% 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 68.29% (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 31.71% 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 81808UT0020003
Health Insurance Plan Year 2023
State Utah
Health Insurance Issuer Cigna Health and Life Insurance Company
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 81808UT0020003-00
Provider Network(s) ['UTN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Wed, 27 Mar 2024 12:10 GMT).

Providers Utah All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 81808UT0020003-00

Standard On Exchange Plan - 81808UT0020003-01

Open to Indians below 300% FPL - 81808UT0020003-02

Open to Indians above 300% FPL - 81808UT0020003-03

Last Plan Update Date Thu, 23 Feb 2023 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Cigna Connect 3500 Health Insurance Plan, 81808UT0020003-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental
NO
Acupuncture
NO
Allergy Testing
YES

50.00% Coinsurance after deductible

100.00%
Autism Spectrum Disorders

Includes ABA Therapy. Prior authorization required.

YES

50.00% Coinsurance after deductible

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

50.00% Coinsurance after deductible

100.00%
Chiropractic Care
NO
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care

The per day inpatient copayment will apply for a maximum of three (3) days.

YES

$2000.00 Copay after deductible

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% Coinsurance after deductible

100.00%
Durable Medical Equipment
YES

50.00% Coinsurance 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

$1,500.00 Copay after deductible

$1,500.00 Copay 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

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

For children up to age 19. 1 pair of glasses (lenses and frames from pediatric selection) per 12 month period. Contact lenses are covered for one pair or a single purchase of a supply of contact lenses, including professional services, in lieu of frame and lenses.

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 a 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

$3.00

100.00%
Habilitation Services

Services for physical therapy, occupational therapy and speech therapy have a maximum of 20 visits per calendar year, all services combined.

YES

50.00% Coinsurance after deductible

100.00%
Hearing Aids
NO
Home Health Care Services

Limit: 30.0 Visit(s) per Year

YES

50.00% Coinsurance after deductible

100.00%
Hospice Services
YES

50.00% Coinsurance after deductible

100.00%
Imaging (CT/PET Scans, MRIs)
YES

50.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

50.00% Coinsurance after deductible

100.00%
Inherited Metabolic Disorder - PKU
YES

50.00% Coinsurance after deductible

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)

The per day inpatient copayment will apply for a maximum of three (3) days.

YES

$2000.00 Copay per Day after deductible

100.00%
Inpatient Physician and Surgical Services
YES

50.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services

Some laboratory tests for Diabetes are covered at no charge. Refer to the policy for more information.

YES

$50.00

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 three (3) days.

YES

$2000.00 Copay per Day after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

50.00% Coinsurance 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 90 day Retail Pharmacy.

YES

50.00% Coinsurance after deductible

100.00%
Nutritional Counseling
NO
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

50.00% Coinsurance after deductible

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

50.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Services for physical therapy, occupational therapy and speech therapy have a maximum of 20 visits per calendar year, all services combined. Services for cardiac and pulmonary rehabilitation have a maximum of 5 visits per calendar year, all services combined.

YES

50.00% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

50.00% Coinsurance 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 90 day Retail Pharmacy. Formulary Diabetic Supplies are covered at no charge. Refer to the prescription drug list for more information.

YES

50.00% Coinsurance after deductible

100.00%
Prenatal and Postnatal Care
YES

50.00% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization
YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness

Refer to the policy for more information about Virtual Care Services.

YES

No Charge

100.00%
Private-Duty Nursing
NO
Prosthetic Devices
YES

50.00% Coinsurance after deductible

100.00%
Radiation
YES

50.00% Coinsurance after deductible

100.00%
Reconstructive Surgery
YES

50.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Services for physical therapy, occupational therapy and speech therapy have a maximum of 20 visits per calendar year, all services combined.

YES

50.00% Coinsurance after deductible

100.00%
Rehabilitative Speech Therapy

Services for speech therapy have a 20 visit limit per calendar year combined with physical and occupational therapy.

YES

50.00% Coinsurance after deductible

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Year

For children up to age 19.

YES

No Charge

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 30.0 Days per Year

YES

50.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

50.00% Coinsurance after deductible

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 90 day Retail 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 three (3) days.

YES

$2000.00 Copay per Day after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

50.00% Coinsurance after deductible

100.00%
Transplant

Lifesource Travel benefit - unlimited, per insured person, per transplant

YES

50.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
NO
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

$45.00

$45.00
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

50.00% Coinsurance after deductible

100.00%

Cigna Connect 3500 Health Insurance Plan Variant 81808UT0020003-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.68285801
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2023
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Bronze 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 $10000 per group
Drug EHB Deductible, In Network (Tier 1), Family Per Person $5000 per person
Drug EHB Deductible, In Network (Tier 1), Individual $5,000
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
First Tier Utilization 100%
Formulary ID UTF001
Formulary URL URL
HIOS Product ID 81808UT002
Import Date 2/23/2023 20:01
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 64.23%
Issuer ID 81808
Issuer Marketplace Marketing Name Cigna Healthcare
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 $7000 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person $3500 per person
Medical EHB Deductible, In Network (Tier 1), Individual $3,500
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 Expanded Bronze
Multiple In Network Tiers No
National Network No
Network ID UTN001
Out of Country Coverage No
Out of Country Coverage Description Emergency Services Only
Out of Service Area Coverage No
Out of Service Area Coverage Description Emergency Services Only
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 81808UT0020003-00
Plan Marketing Name Cigna Connect 3500
Plan Type EPO
Plan Variant Marketing Name Cigna Connect 3500
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $400
SBC Scenario, Having a Baby, Copayment $4,500
SBC Scenario, Having a Baby, Deductible $3,500
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $500
SBC Scenario, Having Diabetes, Deductible $1,100
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $0
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,400
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID UTS001
Source Name SERFF
Plan ID 81808UT0020003
State Code UT
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 $18200 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $9100 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $9,100
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 Cigna Connect 3500 Health Insurance Plan, 81808UT0020003

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Cigna Connect 3500, 81808UT0020003 Health Insurance Plan, 81808UT0020003

  • Does Cigna Connect 3500 Health Insurance Plan, 81808UT0020003 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (81808UT0020003) Health Insurance Plan, Variant (81808UT0020003-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy

    Does (81808UT0020003) Health Insurance Plan, Variant (81808UT0020003-00) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan). Details: Emergency Services Only

    Does (81808UT0020003) Health Insurance Plan, Variant (81808UT0020003-00) have Out of Service Area Coverage?

    No, unfortunately there is no Out of Service Area Coverage for this Health Insurance Plan (variant of plan). Details: Emergency Services Only

    Does (81808UT0020003) Health Insurance Plan, Variant (81808UT0020003-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy

    Does Cigna Connect 3500 Health Insurance Plan, Variant (81808UT0020003-00) offer Disease Management Programs for Asthma?

    Yes, the Cigna Connect 3500 Health Insurance Plan Variant 81808UT0020003-00 offers Disease Management Program for Asthma.

    Does Cigna Connect 3500 Health Insurance Plan, Variant (81808UT0020003-00) offer Disease Management Programs for Heart disease?

    Yes, the Cigna Connect 3500 Health Insurance Plan Variant 81808UT0020003-00 offers Disease Management Program for Heart disease.

    Does Cigna Connect 3500 Health Insurance Plan, Variant (81808UT0020003-00) offer Disease Management Programs for Diabetes?

    Yes, the Cigna Connect 3500 Health Insurance Plan Variant 81808UT0020003-00 offers Disease Management Program for Diabetes.

    Does Cigna Connect 3500 Health Insurance Plan, Variant (81808UT0020003-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Cigna Connect 3500 Health Insurance Plan Variant 81808UT0020003-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Cigna Connect 3500 Health Insurance Plan, Variant (81808UT0020003-00) offer Disease Management Programs for Pregnancy?

    Yes, the Cigna Connect 3500 Health Insurance Plan Variant 81808UT0020003-00 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Wed, 27 Mar 2024 12:10 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