Cigna HealthCare of Texas, Inc.

Connect Gold DFW 2500 Indiv Med Deductible Enhanced Diabetes Care

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Plan Overview

Combined Medical and Drug Deductible	Individual: $2,500.00 Family: $5000 Per Person: $2500
Combined Medical and Drug Out of Pocket Maximum	Individual: $7,750.00 Family: $15500 Per Person: $7750

Office Visit

Primary Doctor	CoPay: $10.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Refer to the policy for more information about Virtual Care Services.
Specialist	CoPay: $40.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $40.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: You pay a copayment for each 30 day supply. Up to a 30-day supply at any Participating Pharmacy or up to a 90-day supply at a Designated 90-day Retail Pharmacy. Formulary Diabetic Supplies, Metformin, and Preferred Insulin covered at No Charge. Refer to the prescription drug list for more information.
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 49.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Up to a 30-day supply at any Participating Pharmacy or up to a 90-day supply at a Designated 90-day Retail Pharmacy. Formulary Diabetic Supplies, Metformin, and Preferred Insulin covered at No Charge. Refer to the prescription drug list for more information.
Generic Drugs	CoPay: No Charge CoInsurance: Not Applicable 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. Up to a 30-day supply at any Participating Pharmacy, or up to a 90-day supply at any Designated 90-day Retail Pharmacy. Formulary Diabetic Supplies, Metformin, and Preferred Insulin 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. Up to a 30-day supply at any Participating Pharmacy or up to a 30-day supply at a Designated 90-day Retail Pharmacy. Refer to the prescription drug list for more information.

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $400.00 CoInsurance: 20.00% 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: $30.00 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: 20.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 20.00% 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: Limited to one exam per year

Major Dental Care

Routine Dental Checkups for Children

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.