Cigna Health and Life Insurance Company

Cigna Plus with Northwestern Medicine 5000 ($0 Telehealth)

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Plan Overview

Combined Medical and Drug Deductible	Individual: $5,000 Family: $10,000 Per Person: $5,000
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,700 Family: $17,400 Per Person: $8,700

Office Visit

Primary Doctor	CoPay: $75.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Virtual medical visit with a Dedicated Virtual Care Physician is covered at No Charge. Refer to the policy for more information. Includes Mental Health Office Visits and Substance Use Disorder Office Visits.
Specialist	CoPay: $90.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered Benefit Explanation: 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.
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: 30 day supply at any Participating Pharmacy or Up to a 90 day supply at a 90 day Retail Pharmacy.
Generic Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: 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. 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.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Including other high cost drugs. 30 day supply at any Participating Pharmacy or Up to a 90 day supply at a 90 day Retail Pharmacy.

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Out-of-network: You pay the same level as in-network if it is an emergency as defined in your plan, otherwise Not covered.
Urgent Care Facility	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Out-of-network: You pay the same level as in-network if it is an emergency as defined in your plan, otherwise Not covered.

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: Not Applicable
CoInsurance: No Charge
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year
Benefit Explanation: Children up to age 19, through the end of their birth month.

Major Dental Care

Routine Dental Checkups for Children	Covered: Not Covered
Basic Dental Care - Child	Covered: Not Covered
Major Dental Care - Child	Covered: Not Covered

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Cigna HealthCare of Arizona, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of North Carolina, Inc. and Cigna Dental Health, Inc. The Cigna name, logo and other Cigna marks are owned by Cigna Intellectual Property, Inc.
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