Connect Gold CMS Standard - 73943NC0070050 Health Insurance Plan
Cigna HealthCare of North Carolina, Inc. health insurance plan with the Plan ID 73943NC0070050. The plan is called Connect Gold CMS Standard.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.06% (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 21.94% 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 | 73943NC0070050 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | North Carolina | ||||||||||||||||||
| Health Insurance Issuer | Cigna HealthCare of North Carolina, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 73943NC0070050-01 | ||||||||||||||||||
| Provider Network(s) | ['NCN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 11 Nov 2025 05:33 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 73943NC0070050-00 Standard On Exchange Plan - 73943NC0070050-01 |
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| Last Plan Update Date | Thu, 15 Aug 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 11 Nov 2025 05:33 GMT |
Benefits of Connect Gold CMS Standard Health Insurance Plan, 73943NC0070050-01
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Exclusions: nan nan |
NO | ||
| Accidental Dental
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Acupuncture
Exclusions: nan nan |
NO | ||
| Allergy Testing
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Basic Dental Care - Adult
Exclusions: nan nan |
NO | ||
| Basic Dental Care - Child
Exclusions: nan nan |
NO | ||
| Chemotherapy
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Exclusions: nan 30 visit limit for Physical Therapy and Occupational Therapy combined (including chiropractic). PCP copay applies for Physical and Occupational Therapy visits and Chiropractic visits. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Cosmetic Surgery
Exclusions: nan nan |
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
Exclusions: nan nan |
NO | ||
| Diabetes Education
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Dialysis
Exclusions: nan Benefit depends on place of treatment. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
Exclusions: nan 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 | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
Exclusions: nan 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 | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Exclusions: nan Children up to age 19. Limited to 1 pair of glasses (lenses and frames from pediatric selection) per 12 month period. |
YES | No Charge |
100.00% |
| Gender Affirming Care
Exclusions: nan nan |
NO | ||
| Generic Drugs
Exclusions: nan 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 Pharmacy. Refer to the prescription drug list for more information. |
YES | $15.00 |
100.00% |
| Habilitation Services
Exclusions: nan Combined 30 visit limit for occupational and physical therapies. Speech Therapy limited to 30 visits per year. PCP copay applies for Physical and Occupational Therapy visits and Chiropractic visits. |
YES | $30.00 |
100.00% |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years Exclusions: nan Limited to one hearing aid, per hearing impaired ear, every 36 months. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Home Health Care Services
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Hospice Services
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
Exclusions: nan Includes services related to the diagnosis, treatment and correction of conditions resulting in infertility. Excludes treatment of infertility such as in vitro fertilization and other types of artificial or surgical means of conception and associated procedures and the related medications are Not Covered. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Infusion Therapy
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
Exclusions: nan nan |
NO | ||
| Major Dental Care - Adult
Exclusions: nan nan |
NO | ||
| Major Dental Care - Child
Exclusions: nan nan |
NO | ||
| Mental/Behavioral Health Inpatient Services
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Exclusions: nan 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 | $30.00 |
100.00% |
| Non-Preferred Brand Drugs
Exclusions: nan 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 Pharmacy. Refer to the prescription drug list for more information. |
YES | $60.00 |
100.00% |
| Nutritional Counseling
Exclusions: nan Limited to preventive services only, as part of the Preventive Care benefit. |
YES | No Charge |
100.00% |
| Orthodontia - Adult
Exclusions: nan nan |
NO | ||
| Orthodontia - Child
Exclusions: nan nan |
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Exclusions: nan nan |
YES | $60.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Exclusions: nan Cardiac Rehabilitation limited to 30 visits per year; Pulmonary Rehabilitation limited to 1 course per year. Physical Therapy, Occupational Therapy, Chiropractic Care limited to 30 combined visits per year; Speech Therapy limited to 30 visits per year. PCP copay applies for Physical and Occupational Therapy visits and Chiropractic visits. |
YES | $30.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
Exclusions: nan 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 Pharmacy. Refer to the prescription drug list for more information. |
YES | $30.00 |
100.00% |
| Prenatal and Postnatal Care
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Preventive Care/Screening/Immunization
Exclusions: nan Routine physicals and other preventive services. |
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Exclusions: nan Includes Mental Health Office Visits and Substance Use Disorder Office Visits. Refer to the policy for more information about Virtual Care Services. |
YES | $30.00 |
100.00% |
| Private-Duty Nursing
Exclusions: nan Medically necessary care while receiving active care management, prior authorization required. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Prosthetic Devices
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Radiation
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Exclusions: nan Benefits include coverage for congenital defects of newborn, adopted, and foster children; reconstruction following a mastectomy. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Exclusions: nan Combined 30 visit limit for occupational and physical therapies and chiropractic services. |
YES | $30.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year Exclusions: nan nan |
YES | $30.00 |
100.00% |
| Routine Dental Services (Adult)
Exclusions: nan nan |
NO | ||
| Routine Eye Exam (Adult)
Exclusions: nan nan |
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year Exclusions: nan Children up to age 19. Limited to 1 visit per 12 month period. |
YES | No Charge |
100.00% |
| Routine Foot Care
Exclusions: nan nan |
NO | ||
| Skilled Nursing Facility
Limit: 60.0 Days per Year Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
Exclusions: nan nan |
YES | $60.00 |
100.00% |
| Specialty Drugs
Exclusions: nan Including other high cost drugs. 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 Pharmacy. Refer to the prescription drug list for more information. |
YES | $250.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Exclusions: nan 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 | $30.00 |
100.00% |
| Transplant
Exclusions: nan See policy for additional information on Cigna LifeSOURCE Designated Transplant Network Facility. |
YES | No Charge after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
Exclusions: nan 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 | $45.00 |
$45.00 |
| Weight Loss Programs
Exclusions: nan nan |
NO | ||
| Well Baby Visits and Care
Exclusions: nan nan |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
Connect Gold CMS Standard Health Insurance Plan Variant 73943NC0070050-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.780612576352931 |
| 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 Gold On Exchange Plan |
| Dental Only Plan | No |
| Design Type | Design 1 |
| Disease Management Programs Offered | Asthma, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Pregnancy |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | NCF008 |
| Formulary URL | URL |
| HIOS Product ID | 73943NC007 |
| 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 | 73943 |
| Issuer Marketplace Marketing Name | Cigna Healthcare |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | NCN001 |
| 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) | 73943NC0070050-01 |
| Plan Marketing Name | Connect Gold CMS Standard |
| Plan Type | HMO |
| Plan Variant Marketing Name | Connect Gold CMS Standard |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,800 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $1,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $800 |
| SBC Scenario, Having Diabetes, Deductible | $900 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $50 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $300 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | NCS001 |
| Source Name | HIOS |
| Plan ID | 73943NC0070050 |
| State Code | NC |
| 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 | 25.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $3000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,500 |
| 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 | $15600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7800 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,800 |
| 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 Gold CMS Standard Health Insurance Plan, 73943NC0070050
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Connect Gold CMS Standard, 73943NC0070050 Health Insurance Plan, 73943NC0070050
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Does Connect Gold CMS Standard Health Insurance Plan, 73943NC0070050 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (73943NC0070050) Health Insurance Plan, Variant (73943NC0070050-01) offer Disease Management Programs?
Does (73943NC0070050) Health Insurance Plan, Variant (73943NC0070050-01) have Out Of Country Coverage?
Does (73943NC0070050) Health Insurance Plan, Variant (73943NC0070050-01) have Out of Service Area Coverage?
Does (73943NC0070050) Health Insurance Plan, Variant (73943NC0070050-01) offer Disease Management Programs?
Does Connect Gold CMS Standard Health Insurance Plan, Variant (73943NC0070050-01) offer Disease Management Programs for Asthma?
Does Connect Gold CMS Standard Health Insurance Plan, Variant (73943NC0070050-01) offer Disease Management Programs for Heart disease?
Does Connect Gold CMS Standard Health Insurance Plan, Variant (73943NC0070050-01) offer Disease Management Programs for Diabetes?
Does Connect Gold CMS Standard Health Insurance Plan, Variant (73943NC0070050-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Connect Gold CMS Standard Health Insurance Plan, Variant (73943NC0070050-01) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 11 Nov 2025 05:33 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