Connect Silver 7000 Indiv Med Deductible - 94419IN0010009 Health Insurance Plan
Cigna Health and Life Insurance Company health insurance plan with the Plan ID 94419IN0010009. The plan is called Connect Silver 7000 Indiv Med Deductible.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 87.01% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 12.99% of the costs of all covered benefits (according to the Issuer).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 87.89% (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 12.11% 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 | 94419IN0010009 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Indiana | ||||||||||||||||||
| Health Insurance Issuer | Cigna Health and Life Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 94419IN0010009-05 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 04 Nov 2025 05:30 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 94419IN0010009-00 Standard On Exchange Plan - 94419IN0010009-01 Open to Indians below 300% FPL - 94419IN0010009-02 Open to Indians above 300% FPL - 94419IN0010009-03 73% AV Silver Plan - 94419IN0010009-04 |
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| Last Plan Update Date | Wed, 20 Nov 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 04 Nov 2025 05:30 GMT |
Benefits of Connect Silver 7000 Indiv Med Deductible Health Insurance Plan, 94419IN0010009-05
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Exclusions: nan nan |
NO | ||
| Accidental Dental
Exclusions: nan Limited to treatment for accidental injury to natural teeth within 12 months of the accidental injury. Anesthesia and hospital charges for dental care, for a member less than 19 years of age or a member who is physically or mentally disabled, are covered if the member requires dental treatment to be given in a hospital or outpatient ambulatory surgical facility. The indications for General Anesthesia, as published in the reference manual of the American Academy of Pediatric Dentistry, should be used to determine whether performing dental procedures is necessary to treat the member's condition under general anesthesia. This coverage does not apply to treatment for TMJ. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Acupuncture
Exclusions: nan nan |
NO | ||
| Allergy Testing
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
Exclusions: nan nan |
NO | ||
| Basic Dental Care - Adult
Exclusions: nan nan |
NO | ||
| Basic Dental Care - Child
Exclusions: nan nan |
NO | ||
| Chemotherapy
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 12.0 Visit(s) per Year Exclusions: nan Includes Osteopathic/Manipulation Therapy. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Cosmetic Surgery
Exclusions: nan nan |
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
Exclusions: nan nan |
NO | ||
| Diabetes Education
Exclusions: nan Including nutritional therapy. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Dialysis
Exclusions: nan Benefit depends on place of treatment. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
Exclusions: nan Maximum of 1 wig per Insured Person, per year. |
YES | 30.00% 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 | 30.00% Coinsurance after deductible |
30.00% 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 | 30.00% Coinsurance after deductible |
30.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Exclusions: nan Children up to age 19, through the end of their birth month. 1 pair of glasses (lenses and frames from pediatric selection) per 12 month period. Contact lenses for Children - One pair or one box per eye of contact lenses, including professional services - in lieu of lenses and frame benefit, (may not receive contact lenses and frames in same benefit year). |
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. 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 a Participating Pharmacy, or up to a 90-day supply at a Designated 90-day Retail Pharmacy. Refer to the prescription drug list for more information. |
YES | $3.00 |
100.00% |
| Habilitation Services
Exclusions: nan Physical therapy limited to 20 visits per year; Occupational therapy limited to 20 visits per year; Speech therapy limited to 20 visits per year. Maximums for Habilitative Services do not reduce maximums for Rehabilitation Services. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Hearing Aids
Exclusions: nan nan |
NO | ||
| Home Health Care Services
Limit: 100.0 Visit(s) per Year Exclusions: nan Maximum does not include home infusion therapy or private duty nursing rendered in the home. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Hospice Services
Exclusions: nan Short-term Inpatient Hospital care when needed in periods of crisis or as respite care. Skilled nursing services, home health aide services, and homemaker/custodial care services given by or under the supervision of a registered nurse. Social services and counseling services from a licensed social worker. Nutritional support such as intravenous feeding and feeding tubes. Physical therapy, occupational therapy, speech therapy, and respiratory therapy given by a licensed therapist. Pharmaceuticals, medical equipment, and supplies needed for pain management and the palliative care of your condition, including oxygen and related respiratory therapy supplies. Bereavement (grief) services, including a review of the needs of the bereaved family and the development of a care plan to meet those needs, both before and after the Member's death. Bereavement services are available to surviving Members for one year after the Member's death.. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
Exclusions: nan nan |
NO | ||
| Infusion Therapy
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
Exclusions: nan nan |
YES | 30.00% 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 | 30.00% 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 Up to a 30-day supply at a Participating Pharmacy or up to a 90-day supply at a Designated 90-day Retail Pharmacy. Refer to the prescription drug list for more information. |
YES | 49.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
Exclusions: nan . |
YES | 30.00% Coinsurance after deductible |
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 | $45.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Exclusions: nan Physical therapy limited to 20 visits per year; Occupational therapy limited to 20 visits per year; Speech therapy limited to 20 visits per year. Maximums for Habilitative Services do not reduce maximums for Rehabilitation Services. Cardiac Rehabilitation limited to 36 visits per year. Pulmonary Rehabilitation limited to 20 visits per year. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
Exclusions: nan nan |
YES | 30.00% 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 a Participating Pharmacy or up to a 90-day supply at a Designated 90-day Retail Pharmacy. Refer to the prescription drug list for more information. |
YES | $40.00 |
100.00% |
| Prenatal and Postnatal Care
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Preventive Care/Screening/Immunization
Exclusions: nan nan |
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Exclusions: nan Refer to the policy for more information about Virtual Care Services. |
YES | No Charge |
100.00% |
| Private-Duty Nursing
Limit: 82.0 Visit(s) per Year Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Prosthetic Devices
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Radiation
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Exclusions: nan Limited to 20 visits per year for Occupational therapy and 20 visits per year for Physical therapy; same visits and coverage apply to habilitative services. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year Exclusions: nan Same limits and coverage apply for habilitative services. |
YES | 30.00% Coinsurance after deductible |
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, through the end of their birth month. |
YES | No Charge |
100.00% |
| Routine Foot Care
Exclusions: nan nan |
NO | ||
| Skilled Nursing Facility
Limit: 90.0 Days per Year Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
Exclusions: nan Includes Mental Health Office Visits and Substance Use Disorder Office Visits. |
YES | $45.00 |
100.00% |
| Specialty Drugs
Exclusions: nan Including other high cost drugs. Up to a 30-day supply at a 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. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Exclusions: nan nan |
YES | 30.00% 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% |
| Tier 2 Generic Drugs
Exclusions: nan You pay a copayment for each 30 day supply. Up to a 30 day supply at any Designated pharmacy, or up to a 90 day supply at any Designated 90 day retail pharmacy. Refer to the prescription drug list for more information. |
YES | $15.00 |
100.00% |
| Transplant
Exclusions: nan Lifesource Travel maximum of $10,000 per transplant. Includes coverage for unrelated donor search services up to $30,000 per transplant; prior authorization required. 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 | 30.00% 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 | 30.00% Coinsurance after deductible |
100.00% |
Connect Silver-3 500 Indiv Med Deductible Health Insurance Plan Variant 94419IN0010009-05 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.878933993005302 |
| 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 | 87% AV Level Silver Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| 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 | INF002 |
| Formulary URL | URL |
| HIOS Product ID | 94419IN001 |
| Import Date | 2024-11-20 00:01:43 |
| 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 Actuarial Value | 87.01% |
| Issuer ID | 94419 |
| Issuer Marketplace Marketing Name | Cigna Healthcare |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Silver |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | INN001 |
| 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) | 94419IN0010009-05 |
| Plan Marketing Name | Connect Silver 7000 Indiv Med Deductible |
| Plan Type | EPO |
| Plan Variant Marketing Name | Connect Silver-3 500 Indiv Med Deductible |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,600 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $100 |
| SBC Scenario, Having Diabetes, Copayment | $600 |
| SBC Scenario, Having Diabetes, Deductible | $500 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $500 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | INS001 |
| Source Name | HIOS |
| Plan ID | 94419IN0010009 |
| State Code | IN |
| 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 | 30.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $1000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $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 | $6100 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $3050 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $3,050 |
| 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 | Yes |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Connect Silver 7000 Indiv Med Deductible Health Insurance Plan, 94419IN0010009
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Connect Silver 7000 Indiv Med Deductible, 94419IN0010009 Health Insurance Plan, 94419IN0010009
-
Does Connect Silver 7000 Indiv Med Deductible Health Insurance Plan, 94419IN0010009 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (94419IN0010009) Health Insurance Plan, Variant (94419IN0010009-05) offer Disease Management Programs?
Does (94419IN0010009) Health Insurance Plan, Variant (94419IN0010009-05) have Out Of Country Coverage?
Does (94419IN0010009) Health Insurance Plan, Variant (94419IN0010009-05) have Out of Service Area Coverage?
Does (94419IN0010009) Health Insurance Plan, Variant (94419IN0010009-05) offer Disease Management Programs?
Does Connect Silver-3 500 Indiv Med Deductible Health Insurance Plan, Variant (94419IN0010009-05) offer Disease Management Programs for Asthma?
Does Connect Silver-3 500 Indiv Med Deductible Health Insurance Plan, Variant (94419IN0010009-05) offer Disease Management Programs for Heart disease?
Does Connect Silver-3 500 Indiv Med Deductible Health Insurance Plan, Variant (94419IN0010009-05) offer Disease Management Programs for Diabetes?
Does Connect Silver-3 500 Indiv Med Deductible Health Insurance Plan, Variant (94419IN0010009-05) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Connect Silver-3 500 Indiv Med Deductible Health Insurance Plan, Variant (94419IN0010009-05) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 04 Nov 2025 05:30 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