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 09/01/2023
*Plan design and rates may change at any time
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.
