Utilizing the Cigna Network nationwide

Prime Plan

Summary Plan Description In-Network Provider Out-of-Network Provider
Overall deductible $1,200 Individual/$2,400 family $2,400 Individual/$4,800 family
Out of pocket maximum $6,000 Individual/$12,000 family $12,000 Individual/$24,000 family
Preventive services Covered at 100% Deductible and 80% coinsurance
Provider Office / Online Visits
Primary care office visit $35 copay per visit Deductible and 80% coinsurance
Specialist office visit $65 copay per visit Deductible and 80% coinsurance
Mental health outpatient visit $65 copay per visit Deductible and 80% coinsurance
Virtual behavioral health $0 copay per visit N/A
Imaging / Labs
Imaging (CT/PETScan/MRI’s) Deductible and 20% coinsurance Deductible and 80% coinsurance
Diagnostic X-ray Deductible and 20% coinsurance Deductible and 80% coinsurance
Diagnostic lab work Deductible and 20% coinsurance Deductible and 80% coinsurance
Outpatient labs/imaging in hospital1 $300 copay plus deductible and 20% coinsurance Deductible and 80% coinsurance
Hospital Inpatient Stay
Facility fee Deductible and 20% coinsurance Deductible and 80% coinsurance
Physician / Surgeon fee Deductible and 20% coinsurance Deductible and 80% coinsurance
Outpatient Surgery
Facility fee Deductible and 20% coinsurance Deductible and 80% coinsurance
Surgeon fee Deductible and 20% coinsurance Deductible and 80% coinsurance
Emergency Room / Urgent Care
Emergency room care $500 copay / waived if admitted, subject to deductible plus coinsurance Deductible and 80% coinsurance except emergency situation then treated as in-network
Urgent care $40 copay per visit Deductible and 80% coinsurance
Virtual urgent care $0 copay per visit N/A
Prescription Drug Coverage
Generic $0-$15 copay for 30 day supply Not covered
Preferred name brand 20% coinsurance, deductible waived Not covered
Non-Preferred name brand 30% coinsurance, deductible applies Not covered
Pregnancy Care
Office visits Bundled with facility care Deductible and 80% coinsurance
Facility and professional services Deductible and 20% coinsurance Deductible and 80% coinsurance

1 When choosing to do labs or diagnostic imaging at a hospital on an outpatient basis over utilizing a stand alone lab or imaging center.

Rates (monthly premium)
Member $841.00
Member + Spouse $1485.00
Member + child (children) $1450.00
Family $2129.00
ACA Compliant in all 50 states

*Plan summary and rates are the same throughout the USA

*Plan summary as of 04/26/2022

We at Thin Blue Line Benefits Association have set up one navigation link for finding medical providers in your region accessed through the Cigna national network link.

  1. This network link will assist you in finding medical providers within the nationwide Cigna network.
  2. Providers can contract under the name of the medical facility and/or their name so when searching a specific provider please make sure to search both.
  3. Should you be unable to locate a provider in your region please contact us for assistance.

Please enter “continue as guest” and “continue without plan” when prompted during search.

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