Utilizing the Cigna Network nationwide
Ultra Plan
| Summary Plan Description | In-Network Provider | Out-of-Network Provider |
|---|---|---|
| Overall deductible | $500 Individual/$1,000 family | $1,000 Individual/$2,000 family |
| Out of pocket maximum | $4,500 Individual/$9,000 family | $9,000 Individual/$18,000 family |
| Preventive services | Covered at 100% | Deductible and 80% coinsurance |
| Provider Office / Online Visits | ||
| Primary care office visit | $25 copay per visit | Deductible and 80% coinsurance |
| Specialist office visit | $50 copay per visit | Deductible and 80% coinsurance |
| Mental health outpatient visit | $50 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 | Not covered |
| Non-Preferred name brand | 30% coinsurance, deductible applies | Not covered |
| Specialty Rx | 50% 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 or an outpatient basis over utilizing a stand alone lab or imaging center.
| Rates (monthly premium) | |
|---|---|
| Member | $1015.00 |
| Member + Spouse | $1792.00 |
| Member + child (children) | $1750.00 |
| Family | $2569.00 |
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.
- This network link will assist you in finding medical providers within the nationwide Cigna network.
- 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.
- 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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