Connect Bronze CMS Standard - 97667AZ0110032 Health Insurance Plan

Cigna HealthCare of Arizona, Inc health insurance plan with the Plan ID 97667AZ0110032. The plan is called Connect Bronze CMS Standard.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 63.81% (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 36.19% 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 97667AZ0110032
Health Insurance Plan Year 2025
State Arizona
Health Insurance Issuer Cigna HealthCare of Arizona, Inc
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 97667AZ0110032-00
Provider Network(s) PREFERRED
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 10 Dec 2024 06:32 GMT).

Providers Arizona All US States
All 13543 17099
PCP 1233 1392
Allergy 3 3
OB/GYN 98 107
Dentists 5 6
Available Variants of the Health Plan

Standard Off Exchange Plan - 97667AZ0110032-00

Standard On Exchange Plan - 97667AZ0110032-01

Open to Indians below 300% FPL - 97667AZ0110032-02

Open to Indians above 300% FPL - 97667AZ0110032-03

Last Plan Update Date Thu, 15 Aug 2024 00:00 GMT
Last Import Date Tue, 10 Dec 2024 06:32 GMT

Benefits of Connect Bronze CMS Standard Health Insurance Plan, 97667AZ0110032-00

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

50.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

50.00% Coinsurance after deductible

100.00%
Bariatric Surgery

Benefit depends on type of service provided.

YES

50.00% Coinsurance after deductible

100.00%
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

50.00% Coinsurance after deductible

100.00%
Chiropractic Care

Maximum of 20 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
YES

50.00% Coinsurance after deductible

100.00%
Dialysis

Benefit depends on place of treatment.

YES

50.00% Coinsurance after deductible

100.00%
Durable Medical Equipment
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.

YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Eye Glasses for Children

Children up to age 19. Limit 1 pair of glasses (lenses and frames from pediatric selection) per 12 month period. One pair of contact lenses - in lieu of lenses and frames benefit, (may not receive contact lenses and frames in same benefit year).

YES

No Charge

100.00%
Gender Affirming Care
NO
Generic Drugs

You pay a copayment for each 30 day supply. Limited to a 30-day supply at a Participating Pharmacy, or up to a 90-day supply at a Designated 90-day Pharmacy. Refer to the prescription drug list for more information.

YES

$25.00

100.00%
Habilitation Services

Maximum of 60 visits per calendar year, combined with Physical, Occupational, Speech Therapies, Cardiac & Pulmonary Rehabilitation. Maximums for Habilitative Services do not reduce maximums for Rehabilitative Services.

YES

$50.00

100.00%
Hearing Aids

Maximum of 1 hearing aid per ear, per calendar year.

YES

50.00% Coinsurance after deductible

100.00%
Home Health Care Services

Limit: 42.0 Visit(s) per Year

YES

50.00% Coinsurance after deductible

100.00%
Hospice Services
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
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
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 Mental Health Office Visits. All other Outpatient Services are covered at the Outpatient professional services benefit. Please refer to the SBC for more information.

YES

$50.00

100.00%
Non-Preferred Brand Drugs

You pay a copayment for each 30 day supply ,after deductible. Limited to a 30-day supply at a Participating Pharmacy or up to a 90-day supply at a Designated 90-day Pharmacy.

YES

$100.00 Copay after deductible

100.00%
Nutritional Counseling

.

YES

50.00% Coinsurance after deductible

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

Benefit depends on type of service provided and licensure.

YES

$100.00

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

50.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Maximum of 60 visits per calendar year, combined with Physical, Occupational, Speech Therapies, Cardiac & Pulmonary Rehabilitation. Maximums for Habilitative Services do not reduce maximums for Rehabilitative Services.

YES

$50.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

50.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs

You pay a copayment for each 30 day supply, after deductible. Limited to a 30-day supply at a Participating Pharmacy or up to a 90-day supply at a Designated 90-day Pharmacy. Refer to the prescription drug list for more information.

YES

$50.00 Copay after deductible

100.00%
Prenatal and Postnatal Care
YES

50.00% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization
YES

0.00%

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

$50.00

100.00%
Private-Duty Nursing

If determined to be medically necessary; as part of inpatient hospital care coverage.

YES

50.00% Coinsurance after deductible

100.00%
Prosthetic Devices
YES

50.00% Coinsurance after deductible

100.00%
Radiation
YES

50.00% Coinsurance after deductible

100.00%
Reconstructive Surgery
YES

50.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Maximum of 60 visits per calendar year, combined with Physical, Occupational, Speech Therapies, Cardiac & Pulmonary Rehabilitation. Maximums for Habilitative Services do not reduce maximums for Rehabilitative Services.

YES

$50.00

100.00%
Rehabilitative Speech Therapy

Maximum of 60 visits per calendar year, combined with Physical, Occupational, Speech Therapies, Cardiac & Pulmonary Rehabilitation. Maximums for Habilitative Services do not reduce maximums for Rehabilitative Services.

YES

$50.00

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Visit(s) per Year

Children up to age 19.

YES

No Charge

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Maximum of 90 days per calendar year.

YES

50.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$100.00

100.00%
Specialty Drugs

Including other high cost drugs. You pay a copayment for each 30 day supply, after deductible. Limited to a 30-day supply at a Participating Pharmacy or up to a 30-day supply at a Designated 90-day Pharmacy.

YES

$500.00 Copay 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 Substance Abuse Disorder Office Visits. All other Outpatient Services are covered at the Outpatient professional services benefit. Please refer to the SBC for more information.

YES

$50.00

100.00%
Transplant

LifeSource Facility Travel Maximum: $10,000 per insured person, per transplant. See policy for additional information on Cigna LifeSOURCE Designated Transplant Network Facility.

YES

No Charge 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

$75.00

$75.00
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

50.00% Coinsurance after deductible

100.00%

Connect Bronze CMS Standard Health Insurance Plan Variant 97667AZ0110032-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.638091065338329
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2025
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Bronze Off Exchange Plan
Dental Only Plan No
Design Type Design 1
Disease Management Programs Offered Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy
EHB Percent of Total Premium 1.0
First Tier Utilization 100%
Formulary ID AZF007
Formulary URL URL
HIOS Product ID 97667AZ011
Import Date 2024-08-15 01:01:23
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 ID 97667
Issuer Marketplace Marketing Name Cigna HealthCare of Arizona, Inc
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Expanded Bronze
Multiple In Network Tiers No
National Network No
Network ID AZN001
Out of Country Coverage Yes
Out of Country Coverage Description Emergency Only
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Emergency Only
Plan Brochure URL
Plan Effective Date 2025-01-01
Plan Expiration Date 2025-12-31
Plan ID (Standard Component ID with Variant) 97667AZ0110032-00
Plan Marketing Name Connect Bronze CMS Standard
Plan Type HMO
Plan Variant Marketing Name Connect Bronze CMS Standard
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,700
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $7,500
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $1,000
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 $500
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,700
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID AZS001
Source Name HIOS
Plan ID 97667AZ0110032
State Code AZ
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 $15000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $7500 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $7,500
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 $18400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $9200 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $9,200
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 No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Connect Bronze CMS Standard Health Insurance Plan, 97667AZ0110032

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

Frequently Asked Questions(FAQ) about Connect Bronze CMS Standard, 97667AZ0110032 Health Insurance Plan, 97667AZ0110032

  • Does Connect Bronze CMS Standard Health Insurance Plan, 97667AZ0110032 support Mail Ordering?

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

  • Does (97667AZ0110032) Health Insurance Plan, Variant (97667AZ0110032-00) offer Disease Management Programs?

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

    Does (97667AZ0110032) Health Insurance Plan, Variant (97667AZ0110032-00) have Out Of Country Coverage?

    Yes. Details: Emergency Only

    Does (97667AZ0110032) Health Insurance Plan, Variant (97667AZ0110032-00) have Out of Service Area Coverage?

    Yes. Details: Emergency Only

    Does (97667AZ0110032) Health Insurance Plan, Variant (97667AZ0110032-00) offer Disease Management Programs?

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

    Does Connect Bronze CMS Standard Health Insurance Plan, Variant (97667AZ0110032-00) offer Disease Management Programs for Asthma?

    Yes, the Connect Bronze CMS Standard Health Insurance Plan Variant 97667AZ0110032-00 offers Disease Management Program for Asthma.

    Does Connect Bronze CMS Standard Health Insurance Plan, Variant (97667AZ0110032-00) offer Disease Management Programs for Heart disease?

    Yes, the Connect Bronze CMS Standard Health Insurance Plan Variant 97667AZ0110032-00 offers Disease Management Program for Heart disease.

    Does Connect Bronze CMS Standard Health Insurance Plan, Variant (97667AZ0110032-00) offer Disease Management Programs for Diabetes?

    Yes, the Connect Bronze CMS Standard Health Insurance Plan Variant 97667AZ0110032-00 offers Disease Management Program for Diabetes.

    Does Connect Bronze CMS Standard Health Insurance Plan, Variant (97667AZ0110032-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Connect Bronze CMS Standard Health Insurance Plan Variant 97667AZ0110032-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Connect Bronze CMS Standard Health Insurance Plan, Variant (97667AZ0110032-00) offer Disease Management Programs for Pregnancy?

    Yes, the Connect Bronze CMS Standard Health Insurance Plan Variant 97667AZ0110032-00 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Tue, 10 Dec 2024 06:32 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