| Field | Data |
|---|---|
| Health Insurance Plan ID | 15105GA0020011 |
| Health Insurance Plan Year | 2023 |
| State | Georgia |
| Health Insurance Issuer | Cigna HealthCare of Georgia, Inc. |
| Plan Formulary Description URL | Formulary URL |
| Plan Marketing Materials URL | Marketing URL |
| Last Plan Update Date | Mon, 19 Sep 2022 00:00 GMT |
| Last Import Date | Tue, 21 Mar 2023 13:10 GMT |
| Health Insurance Plan Variant | 15105GA0020011-05 |
| Available Variants of the Health Plan | |
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.879352375 |
| 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 | 87% AV Level Silver 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 |
| First Tier Utilization | 100% |
| Formulary ID | GAF008 |
| Formulary URL | URL |
| HIOS Product ID | 15105GA002 |
| Import Date | 12/17/2022 1:01 |
| 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 | 87.39% |
| Issuer ID | 15105 |
| Issuer Marketplace Marketing Name | Cigna HealthCare of Georgia, Inc |
| 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 | GAN001 |
| 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 | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 15105GA0020011-05 |
| Plan Marketing Name | Cigna Connect 4200 Enhanced Asthma COPD Care |
| Plan Type | HMO |
| Plan Variant Marketing Name | Cigna Connect 750-3 Enhanced Asthma COPD Care |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,300 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $750 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $30 |
| SBC Scenario, Having Diabetes, Copayment | $600 |
| SBC Scenario, Having Diabetes, Deductible | $750 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $300 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $750 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | GAS001 |
| Source Name | HIOS |
| Plan ID | 15105GA0020011 |
| State Code | GA |
| 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 | 20.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $1500 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $750 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $750 |
| TEHBDedOutOfNetFamilyPerGroup | per group not applicable |
| TEHBDedOutOfNetFamilyPerPerson | 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 | $6000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $3000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $3,000 |
| 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 |
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|---|---|---|---|---|---|
| Generic | 1 month in retail | $20.0 | No charge | 0% | YES | |
| Generic | 1 month out retail | $0 | 0% | YES | ||
| Generic | 3 month in mail | $60.0 | No charge | 0% | YES | |
| Generic | 3 month out mail | $0 | 0% | YES | ||
| Non preferred brand | 1 month in retail | $0 | 50.0% | After deductible | YES | |
| Non preferred brand | 1 month out retail | $0 | 0% | YES | ||
| Non preferred brand | 3 month in mail | $0 | 50.0% | After deductible | YES | |
| Non preferred brand | 3 month out mail | $0 | 0% | YES | ||
| Preferred brand | 1 month in retail | $110.0 | No charge | 0% | YES | |
| Preferred brand | 1 month out retail | $0 | 0% | YES | ||
| Preferred brand | 3 month in mail | $330.0 | No charge | 0% | YES | |
| Preferred brand | 3 month out mail | $0 | 0% | YES | ||
| Preferred generic | 1 month in retail | $3.0 | No charge | 0% | YES | |
| Preferred generic | 1 month out retail | $0 | 0% | YES | ||
| Preferred generic | 3 month in mail | $9.0 | No charge | 0% | YES | |
| Preferred generic | 3 month out mail | $0 | 0% | YES | ||
| Specialty | 1 month in mail | $0 | 50.0% | After deductible | YES | |
| Specialty | 1 month in retail | $0 | 50.0% | After deductible | YES | |
| Specialty | 1 month out retail | $0 | 0% | YES | ||
| Specialty | 3 month in mail | $0 | 0% | YES | ||
| Specialty | 3 month out mail | $0 | 0% | YES |
Frequently Asked Questions(FAQ) about Cigna Connect 4200 Enhanced Asthma COPD Care, 15105GA0020011 Health Insurance Plan, 15105GA0020011
Does Cigna Connect 4200 Enhanced Asthma COPD Care Health Insurance Plan, 15105GA0020011 support Mail Ordering?
Yes, Cigna Connect 4200 Enhanced Asthma COPD Care Health Insurance
Plan, 15105GA0020011 supports mail ordering for the next drug tiers: Generic, Non preferred brand, Preferred brand, Preferred generic, Specialty
What are the Generic Medications coinsurance & copay options with Cigna Connect 4200 Enhanced Asthma COPD Care (15105GA0020011) Health Insurance Plan?
For generic drug tier copay (No charge) is $20.0, generic drug tier, generic drug tier copay (No charge) is $60.0, generic drug tier, preferred generic drug tier copay (No charge) is $3.0, preferred generic drug tier, preferred generic drug tier copay (No charge) is $9.0, preferred generic drug tier
What are the copay and coinsurance options for Brand Drugs with Cigna Connect 4200 Enhanced Asthma COPD Care Health Insurance Plan (15105GA0020011)?
For non preferred brand drug tier coinsurance (After deductible) is 50.0%, non preferred brand drug tier, non preferred brand drug tier coinsurance (After deductible) is 50.0%, non preferred brand drug tier, preferred brand drug tier copay (No charge) is $110.0, preferred brand drug tier, preferred brand drug tier copay (No charge) is $330.0, preferred brand drug tier
What are the copay and coinsurance options for Brand Drugs with Cigna Connect 4200 Enhanced Asthma COPD Care Health Insurance Plan (15105GA0020011)?
, non preferred brand drug tier coinsurance (After deductible) is 50.0%, non preferred brand drug tier, non preferred brand drug tier coinsurance (After deductible) is 50.0%, non preferred brand drug tier, preferred brand drug tier copay (No charge) is $110.0, preferred brand drug tier, preferred brand drug tier copay (No charge) is $330.0, preferred brand drug tier
Does (15105GA0020011) Health Insurance Plan, Variant (15105GA0020011-05) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy
Does (15105GA0020011) Health Insurance Plan, Variant (15105GA0020011-05) have Out Of Country Coverage?
Yes. Details: Emergency Services Only
Does (15105GA0020011) Health Insurance Plan, Variant (15105GA0020011-05) have Out of Service Area Coverage?
Yes. Details: Emergency Services Only
Does (15105GA0020011) Health Insurance Plan, Variant (15105GA0020011-05) 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 750-3 Enhanced Asthma COPD Care Health Insurance Plan, Variant (15105GA0020011-05) offer Disease Management Programs for Asthma?
Yes, the Cigna Connect 750-3 Enhanced Asthma COPD Care Health Insurance Plan Variant 15105GA0020011-05 offers Disease Management Program for Asthma.
Does Cigna Connect 750-3 Enhanced Asthma COPD Care Health Insurance Plan, Variant (15105GA0020011-05) offer Disease Management Programs for Heart disease?
Yes, the Cigna Connect 750-3 Enhanced Asthma COPD Care Health Insurance Plan Variant 15105GA0020011-05 offers Disease Management Program for Heart disease.
Does Cigna Connect 750-3 Enhanced Asthma COPD Care Health Insurance Plan, Variant (15105GA0020011-05) offer Disease Management Programs for Diabetes?
Yes, the Cigna Connect 750-3 Enhanced Asthma COPD Care Health Insurance Plan Variant 15105GA0020011-05 offers Disease Management Program for Diabetes.
Does Cigna Connect 750-3 Enhanced Asthma COPD Care Health Insurance Plan, Variant (15105GA0020011-05) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the Cigna Connect 750-3 Enhanced Asthma COPD Care Health Insurance Plan Variant 15105GA0020011-05 offers Disease Management Program for High blood pressure & high cholesterol.
Does Cigna Connect 750-3 Enhanced Asthma COPD Care Health Insurance Plan, Variant (15105GA0020011-05) offer Disease Management Programs for Pregnancy?
Yes, the Cigna Connect 750-3 Enhanced Asthma COPD Care Health Insurance Plan Variant 15105GA0020011-05 offers Disease Management Program for Pregnancy.
Disclaimer: This is based on the import(Date: Tue, 21 Mar 2023 13:10 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