Utilizing the Cigna Network nationwide
Value Plan
| Summary Plan Description | In-Network Provider | Out-of-Network Provider |
|---|---|---|
| Overall deductible | $5,000 Individual/$10,000 family | $10,000 Individual/$20,000 family |
| Out of pocket maximum | $5,000 Individual/$10,000 family | $10,000 Individual/$20,000 family |
| Preventive services | Covered at 100% | Deductible and 80% coinsurance |
| Provider Office / Online Visits | ||
| Primary care office visit1 | $15 copay per visit | Deductible and 80% coinsurance |
| Specialist office visit 1 | $15 copay per visit | Deductible and 80% coinsurance |
| Mental health outpatient visit | Deductible applies then covered 100% | Deductible and 80% coinsurance |
| Virtual behavioral health | $0 copay per visit | N/A |
| Imaging / Labs | ACA preventative procedures are covered in full | |
| Imaging (CT/PETScan/MRI’s) | Deductible applies then covered 100% | Deductible and 80% coinsurance |
| Diagnostic X-ray | Deductible applies then covered 100% | Deductible and 80% coinsurance |
| Diagnostic lab work | Deductible applies then covered 100% | Deductible and 80% coinsurance |
| Hospital Inpatient Stay | ||
| Facility fee | Deductible applies then covered 100% | Deductible and 80% coinsurance |
| Physician / Surgeon fee | Deductible applies then covered 100% | Deductible and 80% coinsurance |
| Outpatient Surgery | ||
| Facility fee | Deductible applies then covered 100% | Deductible and 80% coinsurance |
| Surgeon fee | Deductible applies then covered 100% | Deductible and 80% coinsurance |
| Emergency Room / Urgent Care | ||
| Emergency room care | $1000 copay / waived if admitted | Deductible and 80% coinsurance |
| Urgent care | $50 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 | Not covered | Not covered |
| Non-Preferred name brand | Not covered | Not covered |
| Pregnancy Care | ||
| Office visits | Bundled with facility care | Deductible and 80% coinsurance |
| Facility and professional services | Deductible applies then covered 100% | Deductible and 80% coinsurance |
1 Office visit and labs copays apply to ACA compliant preventative procedures. Diagnostic office visits and lab procedures apply to deductible and coinsurance. Contact care navigator for assistance when needed.
| Rates (monthly premium) | |
|---|---|
| Member | $695.00 |
| Member + Spouse | $1228.00 |
| Member + child (children) | $1200.00 |
| Family | $1762.00 |
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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