Cigna Connect 6000 - 15105GA0020008 Health Insurance Plan

Cigna HealthCare of Georgia, Inc. health insurance plan with the Plan ID 15105GA0020008. The plan is called Cigna Connect 6000.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 70.00% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 30.00% 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 70.98% (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 29.02% 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 15105GA0020008
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
Health Insurance Plan Variant 15105GA0020008-00
Provider Network(s) ['GAN001']
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 Georgia 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 - 15105GA0020008-00

Standard On Exchange Plan - 15105GA0020008-01

Open to Indians below 300% FPL - 15105GA0020008-02

Open to Indians above 300% FPL - 15105GA0020008-03

73% AV Silver Plan - 15105GA0020008-04

87% AV Silver Plan - 15105GA0020008-05

94% AV Silver Plan - 15105GA0020008-06

Last Plan Update Date Sat, 17 Dec 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Cigna Connect 6000 Health Insurance Plan, 15105GA0020008-00

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

Limited to: Treatment which begins within 90 days after the date of the dental injury; and the treatment is completed within 12 months after the date of the dental injury.

YES

50.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
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

Limit: 40.0 Visit(s) per Year

Physical Therapy, Occupational Therapy, Speech Therapy, Audiology, Cognitive Rehabilitation, Spinal Manipulations/Adjustments (Chiropractic Care) Maximum does not apply to services for treatment of Autism Spectrum Disorders. Limited to a combined maximum of 40 visits per calendar year.

YES

50.00% Coinsurance after deductible

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

50.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children
NO
Diabetes Education

Including nutritional therapy.

YES

No Charge

100.00%
Dialysis

Benefit depends on place of treatment.

YES

50.00% Coinsurance after deductible

100.00%
Durable Medical Equipment

Includes orthotics used to support, align, prevent or correct deformities.

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

50.00% Coinsurance after deductible

50.00% Coinsurance 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. Coverage for Medically Necessary transport to the nearest facility capable of handling the Emergency Medical Condition.

YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

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

No Charge

100.00%
Habilitation Services

Limit: 40.0 Visit(s) per Year

Physical Therapy, Occupational Therapy, Speech Therapy Maximum does not apply to services for treatment of Autism Spectrum Disorders. Limited to a combined maximum of 40 visits per calendar year.

YES

50.00% Coinsurance after deductible

100.00%
Hearing Aids
NO
Home Health Care Services

Limit: 120.0 Visit(s) per Year

YES

50.00% Coinsurance after deductible

100.00%
Hospice Services

Life Expectancy of 18 months or less. Excludes Respite Care.

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

Insulin infusion devices.

YES

50.00% Coinsurance after deductible

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

50.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

50.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services

Refer to the policy for more information regarding Diabetes.

YES

50.00% Coinsurance 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

50.00% Coinsurance 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

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 Designated 90 day Retail Pharmacy.

YES

50.00% Coinsurance after deductible

100.00%
Nutritional Counseling

Limit: 4.0 Visit(s) per Year

Nutritional counseling for the treatment of obesity, which includes morbid obesity limited to 4 visits per year. Nutritional counseling for diabetics, unlimited.

YES

50.00% Coinsurance after deductible

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

$80.00

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

50.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 40.0 Visit(s) per Year

Physical Therapy, Occupational Therapy, Speech Therapy, Audiology, Cognitive Rehabilitation, Spinal Manipulations/Adjustments (Chiropractic Care) Maximum does not apply to services for treatment of Autism Spectrum Disorders. Limited to a combined maximum of 40 visits per calendar year.

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 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

$50.00

100.00%
Prenatal and Postnatal Care
YES

50.00% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization

Routine physicals and other preventive services. MDLive Virtual Wellness is covered as Preventive Care.

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

$20.00

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

Reconstructive Surgery to restore a bodily function or to correct a deformity caused by Injury or congenital defect of a Newborn child, or for Medically Necessary Reconstructive Surgery performed to restore symmetry incident to a mastectomy or lumpectomy.

YES

50.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 40.0 Visit(s) per Year

Physical Therapy, Occupational Therapy, Speech Therapy, Audiology, Cognitive Rehabilitation, Spinal Manipulations/Adjustments (Chiropractic Care) Maximum does not apply to services for treatment of Autism Spectrum Disorders. Limited to a combined maximum of 40 visits per calendar year.

YES

50.00% Coinsurance after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 40.0 Visit(s) per Year

Physical Therapy, Occupational Therapy, Speech Therapy, Audiology, Cognitive Rehabilitation, Spinal Manipulations/Adjustments (Chiropractic Care) Maximum does not apply to services for treatment of Autism Spectrum Disorders. Limited to a combined maximum of 40 visits per calendar year.

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

YES

No Charge

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 60.0 Days per Year

YES

50.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$80.00

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

50.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

50.00% Coinsurance 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

50.00% Coinsurance after deductible

100.00%
Tier 2 Generic 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

$25.00

100.00%
Transplant

Limit: 10000.0 Dollars per Procedure

LifeSource Travel and Lodging Benefit Maximum: $10,000 per Insured Person per transplant.

YES

50.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
YES

50.00% Coinsurance 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

$50.00

$50.00
Weight Loss Programs
NO
Well Baby Visits and Care

Care provided for birth through age 5.

YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

50.00% Coinsurance after deductible

100.00%

Cigna Connect 6000 Health Insurance Plan Variant 15105GA0020008-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.709824244
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 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
First Tier Utilization 100%
Formulary ID GAF006
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 70.00%
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) 15105GA0020008-00
Plan Marketing Name Cigna Connect 6000
Plan Type HMO
Plan Variant Marketing Name Cigna Connect 6000
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $3,100
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $6,000
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $600
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 GAS001
Source Name HIOS
Plan ID 15105GA0020008
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 50.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $12000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $6000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $6,000
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 $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 6000 Health Insurance Plan, 15105GA0020008

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

Frequently Asked Questions(FAQ) about Cigna Connect 6000, 15105GA0020008 Health Insurance Plan, 15105GA0020008

  • Does Cigna Connect 6000 Health Insurance Plan, 15105GA0020008 support Mail Ordering?

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

  • Does (15105GA0020008) Health Insurance Plan, Variant (15105GA0020008-00) offer Disease Management Programs?

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

    Does (15105GA0020008) Health Insurance Plan, Variant (15105GA0020008-00) have Out Of Country Coverage?

    Yes. Details: Emergency Services Only

    Does (15105GA0020008) Health Insurance Plan, Variant (15105GA0020008-00) have Out of Service Area Coverage?

    Yes. Details: Emergency Services Only

    Does (15105GA0020008) Health Insurance Plan, Variant (15105GA0020008-00) 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 6000 Health Insurance Plan, Variant (15105GA0020008-00) offer Disease Management Programs for Asthma?

    Yes, the Cigna Connect 6000 Health Insurance Plan Variant 15105GA0020008-00 offers Disease Management Program for Asthma.

    Does Cigna Connect 6000 Health Insurance Plan, Variant (15105GA0020008-00) offer Disease Management Programs for Heart disease?

    Yes, the Cigna Connect 6000 Health Insurance Plan Variant 15105GA0020008-00 offers Disease Management Program for Heart disease.

    Does Cigna Connect 6000 Health Insurance Plan, Variant (15105GA0020008-00) offer Disease Management Programs for Diabetes?

    Yes, the Cigna Connect 6000 Health Insurance Plan Variant 15105GA0020008-00 offers Disease Management Program for Diabetes.

    Does Cigna Connect 6000 Health Insurance Plan, Variant (15105GA0020008-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Cigna Connect 6000 Health Insurance Plan Variant 15105GA0020008-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Cigna Connect 6000 Health Insurance Plan, Variant (15105GA0020008-00) offer Disease Management Programs for Pregnancy?

    Yes, the Cigna Connect 6000 Health Insurance Plan Variant 15105GA0020008-00 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