Cigna Health and Life Insurance Company

Connect Bronze 0/4900 Indiv Medical/Rx Deductible

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Plan Overview

Medical Deductible	Individual: $0 Family: $0 Per Person: $0
Prescription Drug Deductible	Individual: $4,900 Family: $9,800 Per Person: $4,900
Medical Out-of-Pocket Maximum	Individual: $9,200 Family: $18,400 Per Person: $9,200
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: $50 Copay
Specialist	Standard: $120 Copay

Prescription Drug Information

Preferred Brand Drugs	Standard: $250 Copay
Non Preferred Brand Drugs	Standard: 49% Coinsurance after deductible
Generic Drugs	Standard: $3 Copay
Specialty Drugs	Standard: 50% Coinsurance after deductible

Inpatient Coverage

Hospital Services	Standard: $2500 Copay per day
Inpatient Services	Standard: 50% Coinsurance

Emergency and Urgent Care

Emergency Room

Standard: $1700 Copay

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.

Connect Bronze 0/4900 Indiv Medical/Rx Deductible

Plan Overview

Office Visit

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

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