1
2023 Cigna Health Plans
Individual and Family Plans
Cigna HealthCare of Texas, Inc.
944146 09/22
2023 CIGNA IFP HEALTH PLANS
CIGNA CONNECT AND SIMPLE CHOICE PLANS – Texas
Collin, Crosby, Dallas, El Paso, Ellis, Hunt, Johnson, Kaufman, Lubbock, Rockwall, Tarrant
Cigna Connect/Bronze
Cigna Connect 5500 ..................................................................... 2
Cigna Connect 8200 ..................................................................... 2
Cigna Connect 8900 ..................................................................... 2
Cigna Connect 6800 Enhanced Diabetes Care .................. 2
Cigna Connect HSA 7050 ........................................................... 2
Cigna Connect/Silver
Cigna Connect 0A ..........................................................................3
Cigna Connect 0-2 ......................................................................... 3
Cigna Connect 0-3A ...................................................................... 3
Cigna Connect 0-4A ..................................................................... 3
Cigna Connect 3000 .....................................................................4
Cigna Connect 3000-2B ..............................................................4
Cigna Connect 0-3C ......................................................................4
Cigna Connect 0-4C ......................................................................4
Cigna Connect 4000 ..................................................................... 5
Cigna Connect 3250-2 .................................................................. 5
Cigna Connect 0-3B ...................................................................... 5
Cigna Connect 0-4B ...................................................................... 5
Cigna Connect 5000 ..................................................................... 6
Cigna Connect 4600-2 .................................................................6
Cigna Connect 1000-3 ..................................................................6
Cigna Connect 425-4 ....................................................................6
Cigna Connect 7900 ..................................................................... 7
Cigna Connect 7250-2 .................................................................. 7
Cigna Connect 2250-3 .................................................................. 7
Cigna Connect 700-4 ................................................................... 7
Cigna Connect 4200 Enhanced Asthma COPD Care ....... 8
Cigna Connect 3550-2
Enhanced Asthma COPD Care ..................................................8
Cigna Connect 750-3 Enhanced Asthma COPD Care ...... 8
Cigna Connect 50-4 Enhanced Asthma COPD Care ........ 8
Cigna Connect 3800 Enhanced Diabetes Care ..................9
Cigna Connect 3000-2A Enhanced Diabetes Care ...........9
Cigna Connect 600-3 Enhanced Diabetes Care .................9
Cigna Connect 40-4 Enhanced Diabetes Care ...................9
Cigna Connect/Gold
Cigna Connect 2500 ................................................................... 10
Cigna Connect 1900 Enhanced Diabetes Care ................. 10
Cigna Connect Off-Marketplace Only/Bronze
Cigna Connect HSA 4500 ...........................................................11
Cigna Connect Off-Marketplace Only/Gold
Cigna Connect 0B .........................................................................12
Cigna Simple Choice/Bronze
Cigna Simple Choice 7500 ........................................................13
Cigna Simple Choice 9100 .........................................................13
Cigna Simple Choice/Silver
Cigna Simple Choice 5800 ....................................................... 14
Cigna Simple Choice 5700-2 ................................................... 14
Cigna Simple Choice 800-3 ...................................................... 14
Cigna Simple Choice 0-4 ........................................................... 14
Cigna Simple Choice/Gold
Cigna Simple Choice 2000 ....................................................... 14
2
CIGNA CONNECT PLANS – Texas
Collin, Crosby, Dallas, El Paso, Ellis, Hunt, Johnson, Kaufman, Lubbock, Rockwall, Tarrant
2023 Cigna Health Plans
Individual and Family Plans
Cigna HealthCare of Texas, Inc.
BRONZE
Cigna Connect 5500 Cigna Connect 8200 Cigna Connect 8900
Cigna Connect 6800
Enhanced Diabetes Care
Cigna Connect HSA 7050
In-Network In-Network In-Network In-Network In-Network
Annual Deductible
1
(individual/family) $5,500/$11,000 $8,200/$16,400 $8,900/$17,800 $6,800/$13,600 $7,050/$14,100
Coinsurance
2
You pay 50% after deductible You pay 50% after deductible You pay 0% after deductible You pay 40% after deductible You pay 0% after deductible
Annual Out-Of-Pocket Max
3
(individual/family) $9,100/$18,200 $9,100/$18,200 $8,900/$17,800 $9,100/$18,200 $7,050/$14,100
Physician Services (primary care/specialist)
You pay $35, deductible waived/
You pay 50% after deductible
You pay $0, deductible waived/
You pay 50% after deductible
You pay 0% after deductible/
You pay 0% after deductible
You pay $50, deductible waived/
You pay $90, deductible waived
You pay 0% after deductible/
You pay 0% after deductible
Preventive Care
4
You pay $0, deductible waived You pay $0, deductible waived You pay $0, deductible waived You pay $0, deductible waived You pay $0, deductible waived
Inpatient Services (facility/physician) You pay 50% after deductible You pay 50% after deductible You pay 0% after deductible You pay 40% after deductible You pay 0% after deductible
Lab You pay 50% after deductible You pay 50% after deductible You pay 0% after deductible You pay 40% after deductible You pay 0% after deductible
X-ray and Ultrasound You pay 50% after deductible You pay 50% after deductible You pay 0% after deductible You pay 40% after deductible You pay 0% after deductible
Emergency Room Services You pay 50% after deductible You pay 50% after deductible You pay 0% after deductible You pay 40% after deductible You pay 0% after deductible
Urgent Care You pay $75, deductible waived You pay $75, deductible waived You pay 0% after deductible You pay $75, deductible waived You pay 0% after deductible
Virtual Urgent Acute Care
5
You pay $0, deductible waived You pay $0, deductible waived You pay $0, deductible waived You pay $0, deductible waived You pay 0% after deductible
Dedicated Virtual Primary Care Visits You pay $35, deductible waived You pay $0, deductible waived You pay 0% after deductible You pay $50, deductible waived You pay 0% after deductible
Prescription Medications – Tier 1, 2, 3 and 4: Up to a 30-day supply at any participating retail pharmacy or up to a 90-day supply at any participating 90-day retail pharmacy.
Tier 5: Up to a 30-day supply at any participating retail pharmacy or up to a 30-day supply at any participating 90-day retail pharmacy.
Tier 1 - Preferred Generic You pay $10, deductible waived You pay $3, deductible waived You pay 0% after deductible You pay $3, deductible waived You pay 0% after deductible
Tier 2 - Non-Preferred Generic You pay $30, deductible waived You pay 50% after deductible You pay 0% after deductible You pay $30, deductible waived You pay 0% after deductible
Tier 3 - Preferred Brands You pay 50% after deductible You pay 50% after deductible You pay 0% after deductible You pay 40% after deductible You pay 0% after deductible
Tier 4 - Non-Preferred Brands You pay 50% after deductible You pay 50% after deductible You pay 0% after deductible You pay 50% after deductible You pay 0% after deductible
Tier 5 - Specialty and Other High Cost Drugs You pay 50% after deductible You pay 50% after deductible You pay 0% after deductible You pay 50% after deductible You pay 0% after deductible
Formulary Diabetic Supplies, including
Metformin (non-insulin)
You pay 0%, deductible waived You pay 0%, deductible waived You pay 0%, deductible waived You pay 0%, deductible waived You pay 0% after deductible
Preferred Insulin You pay no more than $25 You pay no more than $25 You pay no more than $25 You pay $0, deductible waived You pay no more than $25
MEDICAL
3
CIGNA CONNECT PLANS – Texas
Collin, Crosby, Dallas, El Paso, Ellis, Hunt, Johnson, Kaufman, Lubbock, Rockwall, Tarrant
2023 Cigna Health Plans
Individual and Family Plans
Cigna HealthCare of Texas, Inc.
SILVER
Base Plan Name – Cigna Connect 0A
Cigna Connect 0A Cigna Connect 0-2 Cigna Connect 0-3A Cigna Connect 0-4A
In-Network In-Network In-Network In-Network
Annual Deductible
1
(individual/family)
Medical: $0/$0
Rx: $1,800/$3,600
Medical: $0/$0
Rx: $1,800/$3,600
Medical: $0/$0
Rx: $550/$1,100
$0/$0
Coinsurance
2
You pay 50% You pay 50% You pay 30% You pay 20%
Annual Out-Of-Pocket Max
3
(individual/family) $9,100/$18,200 $7,250/$14,500 $2,700/$5,400 $1,300/$2,600
Physician Services (primary care/specialist) You pay $45/You pay $90 You pay $45/You pay $90 You pay $15/You pay $40 You pay $0/You pay $35
Preventive Care
4
You pay $0 You pay $0 You pay $0 You pay $0
Inpatient Services (facility/physician) You pay 50% You pay 50% You pay 30% You pay 20%
Lab You pay 50% You pay 50% You pay 30% You pay 20%
X-ray and Ultrasound You pay 50% You pay 50% You pay 30% You pay 20%
Emergency Room Services You pay 50% You pay 50% You pay 30% You pay 20%
Urgent Care You pay $90 You pay $90 You pay $40 You pay $35
Virtual Urgent Acute Care
5
You pay $0 You pay $0 You pay $0 You pay $0
Dedicated Virtual Primary Care Visits You pay $45 You pay $45 You pay $15 You pay $0
Prescription Medications – Tier 1, 2, 3 and 4: Up to a 30-day supply at any participating retail pharmacy or up to a 90-day supply at any participating 90-day retail pharmacy.
Tier 5: Up to a 30-day supply at any participating retail pharmacy or up to a 30-day supply at any participating 90-day retail pharmacy.
Tier 1 - Preferred Generic You pay $3, deductible waived You pay $3, deductible waived You pay $3, deductible waived You pay $0
Tier 2 - Non-Preferred Generic You pay $40, deductible waived You pay $33, deductible waived You pay $22, deductible waived You pay $5
Tier 3 - Preferred Brands You pay 40% after deductible You pay 40% after deductible You pay 40% after deductible You pay 20%
Tier 4 - Non-Preferred Brands You pay 50% after deductible You pay 50% after deductible You pay 50% after deductible You pay 50%
Tier 5 - Specialty and Other High Cost Drugs You pay 50% after deductible You pay 50% after deductible You pay 50% after deductible You pay 50%
Formulary Diabetic Supplies, including
Metformin (non-insulin)
You pay 0%, deductible waived You pay 0%, deductible waived You pay 0%, deductible waived You pay 0%
Preferred Insulin You pay no more than $25 You pay no more than $25 You pay no more than $25 You pay no more than $25
MEDICAL
4
CIGNA CONNECT PLANS – Texas
Collin, Crosby, Dallas, El Paso, Ellis, Hunt, Johnson, Kaufman, Lubbock, Rockwall, Tarrant
2023 Cigna Health Plans
Individual and Family Plans
Cigna HealthCare of Texas, Inc.
SILVER
Base Plan Name – Cigna Connect 3000
Cigna Connect 3000 Cigna Connect 3000-2B Cigna Connect 0-3C Cigna Connect 0-4C
In-Network In-Network In-Network In-Network
Annual Deductible
1
(individual/family)
Medical: $3,000/$6,000
Rx: $4,500/$9,000
Medical: $3,000/$6,000
Rx: $4,500/$9,000
Medical: $0/$0
Rx: $500/$1,000
$0/$0
Coinsurance
2
You pay 50% after deductible You pay 50% after deductible You pay 30% You pay 25%
Annual Out-Of-Pocket Max
3
(individual/family) $9,100/$18,200 $7,250/$14,500 $2,900/$5,800 $1,250/$2,500
Physician Services (primary care/specialist) You pay $0, deductible waived/You pay $100, deductible waived You pay $0, deductible waived/You pay $100, deductible waived You pay $0/You pay $50 You pay $0/You pay $25
Preventive Care
4
You pay $0, deductible waived You pay $0, deductible waived You pay $0 You pay $0
Inpatient Services (facility/physician) You pay 50% after deductible You pay 50% after deductible You pay 30% You pay 25%
Lab You pay $50, deductible waived You pay $50, deductible waived You pay $20 You pay $10
X-ray and Ultrasound You pay 50% after deductible You pay 50% after deductible You pay 30% You pay 25%
Emergency Room Services You pay $1,200, deductible waived You pay $1,200, deductible waived You pay $250 You pay $100
Urgent Care You pay $45, deductible waived You pay $45, deductible waived You pay $35 You pay $20
Virtual Urgent Acute Care
5
You pay $0, deductible waived You pay $0, deductible waived You pay $0 You pay $0
Dedicated Virtual Primary Care Visits You pay $0, deductible waived You pay $0, deductible waived You pay $0 You pay $0
Prescription Medications – Tier 1, 2, 3 and 4: Up to a 30-day supply at any participating retail pharmacy or up to a 90-day supply at any participating 90-day retail pharmacy.
Tier 5: Up to a 30-day supply at any participating retail pharmacy or up to a 30-day supply at any participating 90-day retail pharmacy.
Tier 1 - Preferred Generic You pay $3, deductible waived You pay $3, deductible waived You pay $3, deductible waived You pay $3
Tier 2 - Non-Preferred Generic You pay $40, deductible waived You pay $33, deductible waived You pay $25, deductible waived You pay $9
Tier 3 - Preferred Brands You pay $80, deductible waived You pay $70, deductible waived You pay $48, deductible waived You pay $25
Tier 4 - Non-Preferred Brands You pay 50% after deductible You pay 50% after deductible You pay 50% after deductible You pay 50%
Tier 5 - Specialty and Other High Cost Drugs You pay 50% after deductible You pay 50% after deductible You pay 50% after deductible You pay 50%
Formulary Diabetic Supplies, including
Metformin (non-insulin)
You pay 0%, deductible waived You pay 0%, deductible waived You pay 0%, deductible waived You pay 0%
Preferred Insulin You pay no more than $25 You pay no more than $25 You pay no more than $25 You pay no more than $25
MEDICAL
5
CIGNA CONNECT PLANS – Texas
Collin, Crosby, Dallas, El Paso, Ellis, Hunt, Johnson, Kaufman, Lubbock, Rockwall, Tarrant
2023 Cigna Health Plans
Individual and Family Plans
Cigna HealthCare of Texas, Inc.
SILVER
Base Plan Name – Cigna Connect 4000
Cigna Connect 4000 Cigna Connect 3250-2 Cigna Connect 0-3B Cigna Connect 0-4B
In-Network In-Network In-Network In-Network
Annual Deductible
1
(individual/family) $4,000/$8,000 $3,250/$6,500 $0/$0 $0/$0
Coinsurance
2
You pay 50% after deductible You pay 50% after deductible You pay 50% You pay 25%
Annual Out-Of-Pocket Max
3
(individual/family) $9,100/$18,200 $7,250/$14,500 $3,000/$6,000 $1,250/$2,500
Physician Services (primary care/specialist) You pay $25, deductible waived/You pay $45, deductible waived You pay $25, deductible waived/You pay $45, deductible waived You pay $15/You pay $35 You pay $0/You pay $10
Preventive Care
4
You pay $0, deductible waived You pay $0, deductible waived You pay $0 You pay $0
Inpatient Services (facility/physician) You pay 50% after deductible You pay 50% after deductible You pay 50% You pay 25%
Lab You pay 50% after deductible You pay 50% after deductible You pay 50% You pay 25%
X-ray and Ultrasound You pay 50% after deductible You pay 50% after deductible You pay 50% You pay 25%
Emergency Room Services You pay 50% after deductible You pay 50% after deductible You pay 50% You pay 25%
Urgent Care You pay $45, deductible waived You pay $45, deductible waived You pay $35 You pay $10
Virtual Urgent Acute Care
5
You pay $0, deductible waived You pay $0, deductible waived You pay $0 You pay $0
Dedicated Virtual Primary Care Visits You pay $25, deductible waived You pay $25, deductible waived You pay $15 You pay $0
Prescription Medications – Tier 1, 2, 3 and 4: Up to a 30-day supply at any participating retail pharmacy or up to a 90-day supply at any participating 90-day retail pharmacy.
Tier 5: Up to a 30-day supply at any participating retail pharmacy or up to a 30-day supply at any participating 90-day retail pharmacy.
Tier 1 - Preferred Generic You pay $3, deductible waived You pay $3, deductible waived You pay $3 You pay $0
Tier 2 - Non-Preferred Generic You pay $25, deductible waived You pay $25, deductible waived You pay $16 You pay $4
Tier 3 - Preferred Brands You pay 40% after deductible You pay 40% after deductible You pay 40% You pay 35%
Tier 4 - Non-Preferred Brands You pay 50% after deductible You pay 50% after deductible You pay 50% You pay 50%
Tier 5 - Specialty and Other High Cost Drugs You pay 50% after deductible You pay 50% after deductible You pay 50% You pay 50%
Formulary Diabetic Supplies, including
Metformin (non-insulin)
You pay 0%, deductible waived You pay 0%, deductible waived You pay 0% You pay 0%
Preferred Insulin You pay no more than $25 You pay no more than $25 You pay no more than $25 You pay no more than $25
MEDICAL
6
CIGNA CONNECT PLANS – Texas
Collin, Crosby, Dallas, El Paso, Ellis, Hunt, Johnson, Kaufman, Lubbock, Rockwall, Tarrant
2023 Cigna Health Plans
Individual and Family Plans
Cigna HealthCare of Texas, Inc.
SILVER
Base Plan Name – Cigna Connect 5000
Cigna Connect 5000 Cigna Connect 4600-2 Cigna Connect 1000-3 Cigna Connect 425-4
In-Network In-Network In-Network In-Network
Annual Deductible
1
(individual/family) $5,000/$10,000 $4,600/$9,200 $1,000/$2,000 $425/$850
Coinsurance
2
You pay 20% after deductible You pay 20% after deductible You pay 20% after deductible You pay 5% after deductible
Annual Out-Of-Pocket Max
3
(individual/family) $8,000/$16,000 $7,250/$14,500 $3,000/$6,000 $1,000/$2,000
Physician Services (primary care/specialist) You pay $30, deductible waived/You pay $55, deductible waived You pay $20, deductible waived/You pay $40, deductible waived You pay $5, deductible waived/You pay $20, deductible waived You pay $0, deductible waived/You pay $5, deductible waived
Preventive Care
4
You pay $0, deductible waived You pay $0, deductible waived You pay $0, deductible waived You pay $0, deductible waived
Inpatient Services (facility/physician) You pay 20% after deductible You pay 20% after deductible You pay 20% after deductible You pay 5% after deductible
Lab You pay $45, deductible waived You pay $45, deductible waived You pay $20, deductible waived You pay $10, deductible waived
X-ray and Ultrasound You pay 20% after deductible You pay 20% after deductible You pay 20% after deductible You pay 5% after deductible
Emergency Room Services You pay 20% after deductible You pay 20% after deductible You pay 20% after deductible You pay 5% after deductible
Urgent Care You pay $55, deductible waived You pay $40, deductible waived You pay $20, deductible waived You pay $5, deductible waived
Virtual Urgent Acute Care
5
You pay $0, deductible waived You pay $0, deductible waived You pay $0, deductible waived You pay $0, deductible waived
Dedicated Virtual Primary Care Visits You pay $30, deductible waived You pay $20, deductible waived You pay $5, deductible waived You pay $0, deductible waived
Prescription Medications – Tier 1, 2, 3 and 4: Up to a 30-day supply at any participating retail pharmacy or up to a 90-day supply at any participating 90-day retail pharmacy.
Tier 5: Up to a 30-day supply at any participating retail pharmacy or up to a 30-day supply at any participating 90-day retail pharmacy.
Tier 1 - Preferred Generic You pay $3, deductible waived You pay $3, deductible waived You pay $3, deductible waived You pay $0, deductible waived
Tier 2 - Non-Preferred Generic You pay $40, deductible waived You pay $21, deductible waived You pay $10, deductible waived You pay $5, deductible waived
Tier 3 - Preferred Brands You pay 40% after deductible You pay 40% after deductible You pay 30% after deductible You pay 10% after deductible
Tier 4 - Non-Preferred Brands You pay 50% after deductible You pay 50% after deductible You pay 40% after deductible You pay 35% after deductible
Tier 5 - Specialty and Other High Cost Drugs You pay 50% after deductible You pay 50% after deductible You pay 40% after deductible You pay 35% after deductible
Formulary Diabetic Supplies, including
Metformin (non-insulin)
You pay 0%, deductible waived You pay 0%, deductible waived You pay 0%, deductible waived You pay 0%, deductible waived
Preferred Insulin You pay no more than $25 You pay no more than $25 You pay no more than $25 You pay no more than $25
MEDICAL
7
CIGNA CONNECT PLANS – Texas
Collin, Crosby, Dallas, El Paso, Ellis, Hunt, Johnson, Kaufman, Lubbock, Rockwall, Tarrant
2023 Cigna Health Plans
Individual and Family Plans
Cigna HealthCare of Texas, Inc.
SILVER
Base Plan Name – Cigna Connect 7900
Cigna Connect 7900 Cigna Connect 7250-2 Cigna Connect 2250-3 Cigna Connect 700-4
In-Network In-Network In-Network In-Network
Annual Deductible
1
(individual/family) $7,900/$15,800 $7,250/$14,500 $2,250/$4,500 $700/$1,400
Coinsurance
2
You pay 0% after deductible You pay 0% after deductible You pay 0% after deductible You pay 0% after deductible
Annual Out-Of-Pocket Max
3
(individual/family) $7,900/$15,800 $7,250/$14,500 $2,250/$4,500 $700/$1,400
Physician Services (primary care/specialist) You pay $35, deductible waived/You pay $70, deductible waived You pay $25, deductible waived/You pay $50, deductible waived You pay $10, deductible waived/You pay $25, deductible waived You pay $5, deductible waived/You pay $25, deductible waived
Preventive Care
4
You pay $0, deductible waived You pay $0, deductible waived You pay $0, deductible waived You pay $0, deductible waived
Inpatient Services (facility/physician) You pay 0% after deductible You pay 0% after deductible You pay 0% after deductible You pay 0% after deductible
Lab You pay 0% after deductible You pay 0% after deductible You pay 0% after deductible You pay 0% after deductible
X-ray and Ultrasound You pay 0% after deductible You pay 0% after deductible You pay 0% after deductible You pay 0% after deductible
Emergency Room Services You pay 0% after deductible You pay 0% after deductible You pay 0% after deductible You pay 0% after deductible
Urgent Care You pay $70, deductible waived You pay $50, deductible waived You pay $25, deductible waived You pay $25, deductible waived
Virtual Urgent Acute Care
5
You pay $0, deductible waived You pay $0, deductible waived You pay $0, deductible waived You pay $0, deductible waived
Dedicated Virtual Primary Care Visits You pay $35, deductible waived You pay $25, deductible waived You pay $10, deductible waived You pay $5, deductible waived
Prescription Medications – Tier 1, 2, 3 and 4: Up to a 30-day supply at any participating retail pharmacy or up to a 90-day supply at any participating 90-day retail pharmacy.
Tier 5: Up to a 30-day supply at any participating retail pharmacy or up to a 30-day supply at any participating 90-day retail pharmacy.
Tier 1 - Preferred Generic You pay $3, deductible waived You pay $3, deductible waived You pay $3, deductible waived You pay $3, deductible waived
Tier 2 - Non-Preferred Generic You pay $35, deductible waived You pay $18, deductible waived You pay $15, deductible waived You pay $8, deductible waived
Tier 3 - Preferred Brands You pay $55, deductible waived You pay $55, deductible waived You pay $30, deductible waived You pay $30, deductible waived
Tier 4 - Non-Preferred Brands You pay 0% after deductible You pay 0% after deductible You pay 0% after deductible You pay 0% after deductible
Tier 5 - Specialty and Other High Cost Drugs You pay 0% after deductible You pay 0% after deductible You pay 0% after deductible You pay 0% after deductible
Formulary Diabetic Supplies, including
Metformin (non-insulin)
You pay 0%, deductible waived You pay 0%, deductible waived You pay 0%, deductible waived You pay 0%, deductible waived
Preferred Insulin You pay no more than $25 You pay no more than $25 You pay no more than $25 You pay no more than $25
MEDICAL
8
CIGNA CONNECT PLANS – Texas
Collin, Crosby, Dallas, El Paso, Ellis, Hunt, Johnson, Kaufman, Lubbock, Rockwall, Tarrant
2023 Cigna Health Plans
Individual and Family Plans
Cigna HealthCare of Texas, Inc.
SILVER
Base Plan Name – Cigna Connect 4200 Enhanced Asthma COPD Care
Cigna Connect 4200
Enhanced Asthma COPD Care
Cigna Connect 3550-2
Enhanced Asthma COPD Care
Cigna Connect 750-3
Enhanced Asthma COPD Care
Cigna Connect 50-4
Enhanced Asthma COPD Care
In-Network In-Network In-Network In-Network
Annual Deductible
1
(individual/family) $4,200/$8,400 $3,550/$7,100 $750/$1,500 $50/$100
Coinsurance
2
You pay 40% after deductible You pay 35% after deductible You pay 20% after deductible You pay 5% after deductible
Annual Out-Of-Pocket Max
3
(individual/family) $9,100/$18,200 $7,250/$14,500 $3,000/$6,000 $1,650/$3,300
Physician Services (primary care/specialist) You pay $15, deductible waived/You pay $75, deductible waived You pay $15, deductible waived/You pay $75, deductible waived You pay $10, deductible waived/You pay $35, deductible waived You pay $5, deductible waived/You pay $25, deductible waived
Preventive Care
4
You pay $0, deductible waived You pay $0, deductible waived You pay $0, deductible waived You pay $0, deductible waived
Inpatient Services (facility/physician) You pay 40% after deductible You pay 35% after deductible You pay 20% after deductible You pay 5% after deductible
Lab You pay 40% after deductible You pay 35% after deductible You pay 20% after deductible You pay 5% after deductible
X-ray and Ultrasound You pay 40% after deductible You pay 35% after deductible You pay 20% after deductible You pay 5% after deductible
Emergency Room Services You pay 40% after deductible You pay 35% after deductible You pay 20% after deductible You pay 5% after deductible
Urgent Care You pay $35, deductible waived You pay $30, deductible waived You pay $25, deductible waived You pay $15, deductible waived
Virtual Urgent Acute Care
5
You pay $0, deductible waived You pay $0, deductible waived You pay $0, deductible waived You pay $0, deductible waived
Dedicated Virtual Primary Care Visits You pay $15, deductible waived You pay $15, deductible waived You pay $10, deductible waived You pay $5, deductible waived
Prescription Medications – Tier 1, 2, 3 and 4: Up to a 30-day supply at any participating retail pharmacy or up to a 90-day supply at any participating 90-day retail pharmacy.
Tier 5: Up to a 30-day supply at any participating retail pharmacy or up to a 30-day supply at any participating 90-day retail pharmacy.
Tier 1 - Preferred Generic You pay $3, deductible waived You pay $3, deductible waived You pay $3, deductible waived You pay $0, deductible waived
Tier 2 - Non-Preferred Generic You pay $20, deductible waived You pay $20, deductible waived You pay $15, deductible waived You pay $15, deductible waived
Tier 3 - Preferred Brands You pay $110, deductible waived You pay $110, deductible waived You pay $65, deductible waived You pay $20, deductible waived
Tier 4 - Non-Preferred Brands You pay 50% after deductible You pay 50% after deductible You pay 50% after deductible You pay 50% after deductible
Tier 5 - Specialty and Other High Cost Drugs You pay 50% after deductible You pay 50% after deductible You pay 50% after deductible You pay 50% after deductible
Formulary Diabetic Supplies, including
Metformin (non-insulin)
You pay 0%, deductible waived You pay 0%, deductible waived You pay 0%, deductible waived You pay 0%, deductible waived
Preferred Insulin You pay no more than $25 You pay no more than $25 You pay no more than $25 You pay no more than $25
MEDICAL
9
CIGNA CONNECT PLANS – Texas
Collin, Crosby, Dallas, El Paso, Ellis, Hunt, Johnson, Kaufman, Lubbock, Rockwall, Tarrant
2023 Cigna Health Plans
Individual and Family Plans
Cigna HealthCare of Texas, Inc.
SILVER
Base Plan Name – Cigna Connect 3800 Enhanced Diabetes Care
Cigna Connect 3800 Enhanced Diabetes Care Cigna Connect 3000-2A Enhanced Diabetes Care Cigna Connect 600-3 Enhanced Diabetes Care Cigna Connect 40-4 Enhanced Diabetes Care
In-Network In-Network In-Network In-Network
Annual Deductible
1
(individual/family) $3,800/$7,600 $3,000/$6,000 $600/$1,200 $40/$80
Coinsurance
2
You pay 40% after deductible You pay 40% after deductible You pay 25% after deductible You pay 10% after deductible
Annual Out-Of-Pocket Max
3
(individual/family) $9,100/$18,200 $7,250/$14,500 $3,000/$6,000 $1,500/$3,000
Physician Services (primary care/specialist) You pay $20, deductible waived/You pay $80, deductible waived You pay $15, deductible waived/You pay $80, deductible waived You pay $10, deductible waived/You pay $50, deductible waived You pay $0, deductible waived/You pay $20, deductible waived
Preventive Care
4
You pay $0, deductible waived You pay $0, deductible waived You pay $0, deductible waived You pay $0, deductible waived
Inpatient Services (facility/physician) You pay 40% after deductible You pay 40% after deductible You pay 25% after deductible You pay 10% after deductible
Lab You pay 40% after deductible You pay 40% after deductible You pay 25% after deductible You pay 10% after deductible
X-ray and Ultrasound You pay 40% after deductible You pay 40% after deductible You pay 25% after deductible You pay 10% after deductible
Emergency Room Services You pay $1,200, deductible waived You pay $1,200, deductible waived You pay $250, deductible waived You pay $100, deductible waived
Urgent Care You pay $35, deductible waived You pay $30, deductible waived You pay $25, deductible waived You pay $15, deductible waived
Virtual Urgent Acute Care
5
You pay $0, deductible waived You pay $0, deductible waived You pay $0, deductible waived You pay $0, deductible waived
Dedicated Virtual Primary Care Visits You pay $20, deductible waived You pay $15, deductible waived You pay $10, deductible waived You pay $0, deductible waived
Prescription Medications – Tier 1, 2, 3 and 4: Up to a 30-day supply at any participating retail pharmacy or up to a 90-day supply at any participating 90-day retail pharmacy.
Tier 5: Up to a 30-day supply at any participating retail pharmacy or up to a 30-day supply at any participating 90-day retail pharmacy.
Tier 1 - Preferred Generic You pay $3, deductible waived You pay $3, deductible waived You pay $0, deductible waived You pay $0, deductible waived
Tier 2 - Non-Preferred Generic You pay $30, deductible waived You pay $30, deductible waived You pay $15, deductible waived You pay $10, deductible waived
Tier 3 - Preferred Brands You pay $100, deductible waived You pay $75, deductible waived You pay $75, deductible waived You pay $30, deductible waived
Tier 4 - Non-Preferred Brands You pay 50% after deductible You pay 50% after deductible You pay 50% after deductible You pay 50% after deductible
Tier 5 - Specialty and Other High Cost Drugs You pay 50% after deductible You pay 50% after deductible You pay 50% after deductible You pay 50% after deductible
Formulary Diabetic Supplies, including
Metformin (non-insulin)
You pay 0%, deductible waived You pay 0%, deductible waived You pay 0%, deductible waived You pay 0%, deductible waived
Preferred Insulin You pay $0, deductible waived You pay $0, deductible waived You pay $0, deductible waived You pay $0, deductible waived
MEDICAL
10
CIGNA CONNECT PLANS – Texas
Collin, Crosby, Dallas, El Paso, Ellis, Hunt, Johnson, Kaufman, Lubbock, Rockwall, Tarrant
2023 Cigna Health Plans
Individual and Family Plans
Cigna HealthCare of Texas, Inc.
GOLD
Cigna Connect 2500 Cigna Connect 1900 Enhanced Diabetes Care
In-Network In-Network
Annual Deductible
1
(individual/family) $2,500/$5,000 $1,900/$3,800
Coinsurance
2
You pay 30% after deductible You pay 20% after deductible
Annual Out-Of-Pocket Max
3
(individual/family) $6,500/$13,000 $9,100/$18,200
Physician Services (primary care/specialist) You pay $25, deductible waived/You pay $50, deductible waived You pay $15, deductible waived/You pay $50, deductible waived
Preventive Care
4
You pay $0, deductible waived You pay $0, deductible waived
Inpatient Services (facility/physician) You pay 30% after deductible You pay 20% after deductible
Lab You pay $50, deductible waived You pay 20% after deductible
X-ray and Ultrasound You pay 30% after deductible You pay 20% after deductible
Emergency Room Services You pay 30% after deductible You pay 40% after deductible
Urgent Care You pay $75, deductible waived You pay $30, deductible waived
Virtual Urgent Acute Care
5
You pay $0, deductible waived You pay $0, deductible waived
Dedicated Virtual Primary Care Visits You pay $25, deductible waived You pay $15, deductible waived
Prescription Medications – Tier 1, 2, 3 and 4: Up to a 30-day supply at any participating retail pharmacy or up to a 90-day supply at any participating 90-day retail pharmacy.
Tier 5: Up to a 30-day supply at any participating retail pharmacy or up to a 30-day supply at any participating 90-day retail pharmacy.
Tier 1 - Preferred Generic You pay $3, deductible waived You pay $2, deductible waived
Tier 2 - Non-Preferred Generic You pay $15, deductible waived You pay $10, deductible waived
Tier 3 - Preferred Brands You pay $50, deductible waived You pay $50, deductible waived
Tier 4 - Non-Preferred Brands You pay 50% after deductible You pay 50% after deductible
Tier 5 - Specialty and Other High Cost Drugs You pay 50% after deductible You pay 50% after deductible
Formulary Diabetic Supplies, including
Metformin (non-insulin)
You pay 0%, deductible waived You pay 0%, deductible waived
Preferred Insulin You pay no more than $25 You pay $0, deductible waived
G
MEDICAL
11
CIGNA CONNECT PLANS – Texas
Collin, Crosby, Dallas, El Paso, Ellis, Hunt, Johnson, Kaufman, Lubbock, Rockwall, Tarrant
2023 Cigna Health Plans
Individual and Family Plans
Cigna HealthCare of Texas, Inc.
BRONZE
OFF MARKETPLACE ONLY*
Cigna Connect HSA 4500
In-Network
Annual Deductible
1
(individual/family) $4,500/$9,000
Coinsurance
2
You pay 50% after deductible
Annual Out-Of-Pocket Max
3
(individual/family) $7,050/$14,100
Physician Services (primary care/specialist) You pay 50% after deductible/You pay 50% after deductible
Preventive Care
4
You pay $0, deductible waived
Inpatient Services (facility/physician) You pay 50% after deductible
Lab You pay 50% after deductible
X-ray and Ultrasound You pay 50% after deductible
Emergency Room Services You pay 50% after deductible
Urgent Care You pay 50% after deductible
Virtual Urgent Acute Care
5
You pay 0% after deductible
Dedicated Virtual Primary Care Visits You pay 50% after deductible
Prescription Medications – Tier 1, 2, 3 and 4: Up to a 30-day supply at any participating retail pharmacy or up to a 90-day supply at any participating 90-day retail pharmacy.
Tier 5: Up to a 30-day supply at any participating retail pharmacy or up to a 30-day supply at any participating 90-day retail pharmacy.
Tier 1 - Preferred Generic You pay 40% after deductible
Tier 2 - Non-Preferred Generic You pay 40% after deductible
Tier 3 - Preferred Brands You pay 50% after deductible
Tier 4 - Non-Preferred Brands You pay 50% after deductible
Tier 5 - Specialty and Other High Cost Drugs You pay 50% after deductible
Formulary Diabetic Supplies, including
Metformin (non-insulin)
You pay 0% after deductible
Preferred Insulin You pay no more than $25
MEDICAL
12
CIGNA CONNECT PLANS – Texas
Collin, Crosby, Dallas, El Paso, Ellis, Hunt, Johnson, Kaufman, Lubbock, Rockwall, Tarrant
2023 Cigna Health Plans
Individual and Family Plans
Cigna HealthCare of Texas, Inc.
GOLD
OFF MARKETPLACE ONLY*
Cigna Connect 0B
In-Network
Annual Deductible
1
(individual/family) $0/$0
Coinsurance
2
You pay 30%
Annual Out-Of-Pocket Max
3
(individual/family) $8,500/$17,000
Physician Services (primary care/specialist) You pay $40/You pay $75
Preventive Care
4
You pay $0
Inpatient Services (facility/physician) You pay $1,200 per day/You pay 30%
Lab You pay $50
X-ray and Ultrasound You pay 30%
Emergency Room Services You pay $750
Urgent Care You pay $75
Virtual Urgent Acute Care
5
You pay $0
Dedicated Virtual Primary Care Visits You pay $40
Prescription Medications – Tier 1, 2, 3 and 4: Up to a 30-day supply at any participating retail pharmacy or up to a 90-day supply at any participating 90-day retail pharmacy.
Tier 5: Up to a 30-day supply at any participating retail pharmacy or up to a 30-day supply at any participating 90-day retail pharmacy.
Tier 1 - Preferred Generic You pay $3
Tier 2 - Non-Preferred Generic You pay $10
Tier 3 - Preferred Brands You pay $50
Tier 4 - Non-Preferred Brands You pay 50%
Tier 5 - Specialty and Other High Cost Drugs You pay 50%
Formulary Diabetic Supplies, including
Metformin (non-insulin)
You pay 0%
Preferred Insulin You pay no more than $25
MEDICAL
G
13
2023 Cigna Health Plans
Individual and Family Plans
Cigna HealthCare of Texas, Inc.
CIGNA SIMPLE CHOICE PLANS – Texas
Collin, Crosby, Dallas, El Paso, Ellis, Hunt, Johnson, Kaufman, Lubbock, Rockwall, Tarrant
BRONZE
Cigna Simple Choice 7500 Cigna Simple Choice 9100
In-Network In-Network
Annual Deductible
1
(individual/family) $7,500/$15,000 $9,100/$18,200
Coinsurance
2
You pay 50% after deductible You pay 0% after deductible
Annual Out-Of-Pocket Max
3
(individual/family) $9,000/$18,000 $9,100/$18,200
Physician Services (primary care/specialist) You pay $50, deductible waived/You pay $100, deductible waived You pay 0% after deductible/You pay 0% after deductible
Preventive Care
4
You pay $0, deductible waived You pay $0, deductible waived
Inpatient Services (facility/physician) You pay 50% after deductible You pay 0% after deductible
Lab You pay 50% after deductible You pay 0% after deductible
X-ray and Ultrasound You pay 50% after deductible You pay 0% after deductible
Emergency Room Services You pay 50% after deductible You pay 0% after deductible
Urgent Care You pay $75, deductible waived You pay 0% after deductible
Virtual Urgent Acute Care
5
You pay $0, deductible waived You pay $0, deductible waived
Dedicated Virtual Primary Care Visits You pay $50, deductible waived You pay 0% after deductible
Prescription Medications – Tier 1, 2, and 3: Up to a 30-day supply at any participating retail pharmacy or up to a 90-day supply at any participating 90-day retail pharmacy.
Tier 4: Up to a 30-day supply at any participating retail pharmacy or up to a 30-day supply at any participating 90-day retail pharmacy.
Tier 1 - Generic You pay $25, deductible waived You pay 0% after deductible
Tier 2 - Preferred Brand You pay $50 after deductible You pay 0% after deductible
Tier 3 - Non-Preferred Brand You pay $100 after deductible You pay 0% after deductible
Tier 4 - Specialty and Other High Cost Drugs You pay $500 after deductible You pay 0% after deductible
Formulary Diabetic Supplies, including Metformin You pay 0%, deductible waived You pay 0%, deductible waived
Preferred Insulin (Retail) You pay no more than $25 You pay no more than $25
MEDICAL
14
2023 Cigna Health Plans
Individual and Family Plans
Cigna HealthCare of Texas, Inc.
CIGNA SIMPLE CHOICE PLANS – Texas
Collin, Crosby, Dallas, El Paso, Ellis, Hunt, Johnson, Kaufman, Lubbock, Rockwall, Tarrant
SILVER GOLD
Base Plan Name – Cigna Simple Choice 5800
Cigna Simple Choice 5800 Cigna Simple Choice 5700-2 Cigna Simple Choice 800-3 Cigna Simple Choice 0-4 Cigna Simple Choice 2000
In-Network In-Network In-Network In-Network In-Network
Annual Deductible
1
(individual/family) $5,800/$11,600 $5,700/$11,400 $800/$1,600 $0/$0 $2,000/$4,000
Coinsurance
2
You pay 40% after deductible You pay 40% after deductible You pay 30% after deductible You pay 25% You pay 25% after deductible
Annual Out-Of-Pocket Max
3
(individual/family) $8,900/$17,800 $7,200/$14,400 $3,000/$6,000 $1,700/$3,400 $8,700/$17,400
Physician Services (primary care/specialist)
You pay $40, deductible waived/
You pay $80, deductible waived
You pay $30, deductible waived/
You pay $60, deductible waived
You pay $20, deductible waived/
You pay $40, deductible waived
You pay $0/You pay $10
You pay $30, deductible waived/
You pay $60, deductible waived
Preventive Care
4
You pay $0, deductible waived You pay $0, deductible waived You pay $0, deductible waived You pay $0 You pay $0, deductible waived
Inpatient Services (facility/physician) You pay 40% after deductible You pay 40% after deductible You pay 30% after deductible You pay 25% You pay 25% after deductible
Lab You pay 40% after deductible You pay 40% after deductible You pay 30% after deductible You pay 25% You pay 25% after deductible
X-ray and Ultrasound You pay 40% after deductible You pay 40% after deductible You pay 30% after deductible You pay 25% You pay 25% after deductible
Emergency Room Services You pay 40% after deductible You pay 40% after deductible You pay 30% after deductible You pay 25% You pay 25% after deductible
Urgent Care You pay $60, deductible waived You pay $45, deductible waived You pay $30, deductible waived You pay $5 You pay $45, deductible waived
Virtual Urgent Acute Care
5
You pay $0, deductible waived You pay $0, deductible waived You pay $0, deductible waived You pay $0 You pay $0, deductible waived
Dedicated Virtual Primary Care Visits You pay $40, deductible waived You pay $30, deductible waived You pay $20, deductible waived You pay $0 You pay $30, deductible waived
Prescription Medications – Tier 1, 2, and 3: Up to a 30-day supply at any participating retail pharmacy or up to a 90-day supply at any participating 90-day retail pharmacy.
Tier 4: Up to a 30-day supply at any participating retail pharmacy or up to a 30-day supply at any participating 90-day retail pharmacy.
Tier 1 - Generic You pay $20, deductible waived You pay $20, deductible waived You pay $10, deductible waived You pay $0 You pay $15, deductible waived
Tier 2 - Preferred Brand You pay $40, deductible waived You pay $40, deductible waived You pay $20, deductible waived You pay $15 You pay $30, deductible waived
Tier 3 - Non-Preferred Brand You pay $80 after deductible You pay $80 after deductible You pay $60 after deductible You pay $50 You pay $60, deductible waived
Tier 4 - Specialty and Other High Cost Drugs You pay $350 after deductible You pay $350 after deductible You pay $250 after deductible You pay $150 You pay $250, deductible waived
Formulary Diabetic Supplies, including Metformin You pay 0%, deductible waived You pay 0%, deductible waived You pay 0%, deductible waived You pay 0% You pay 0%, deductible waived
Preferred Insulin (Retail) You pay no more than $25 You pay no more than $25 You pay no more than $25 You pay no more than $25 You pay no more than $25
G
MEDICAL
*Unless indicated above, all plans will be available on and off the marketplace.
This summary section contains highlights only. Out-of-network services are not covered under these plans. Eligible out-of-network emergency services are covered at the in-network benefit level as defined in plan documents. Full benefit information, including
plan benefit exclusions and limitations, are available here: https://www.cigna.com/individuals-families/policy. Native Americans and Alaska Natives may qualify for tax credits and special cost-sharing reductions if specific requirements are met. If qualified
Native American/Alaska Natives will pay $0/0% deductible for all eligible plans.
1. Annual Deductible (Individual/family deductible is satisfied when each member has reached their annual individual deductible or when the total annual family deductible amount has been reached by any combination of family members, includes medical and pharmacy).
2. Coinsurance (Amount you pay for covered medical services).
3. Annual Out-of-Pocket Maximum (Individual/family copays, deductibles, coinsurance and pharmacy charges apply to the out-of-pocket maximum).
4. Plans may vary. Includes eligible in-network preventive care services. Some preventive care services may not be covered, including most immunizations for travel. Reference plan documents for a list of covered and non-covered preventive care services.
5. Cigna provides access to Dedicated virtual care through a national telehealth provider, MDLive located on myCigna, as part of your health plan. Providers are solely responsible for any treatment provided to their patients. Video chat may not be available in all areas or with all providers. This service is separate from your health plan’s network and may not be
available in all areas. $0 virtual care benefit for minor acute medical care not available for all plans. HSA plans and non-minor acute medical care may apply a copay, coinsurance or deductible. Virtual care does not guarantee that a prescription will be written. Refer to plan documents for complete description of virtual care services
and costs, including other telehealth/telemedicine benefits. For IL customers a primary care provider referral may be required for specialist virtual visits.
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 Georgia, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of South Carolina, Inc.,
and Cigna HealthCare of Texas, Inc. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.
944146 09/22 © 2022 Cigna
