Cigna Connect 2500 ($0 Telehealth)

13401PA0010015
Gold
EPO

Cigna Connect 2500 ($0 Telehealth) is a Gold EPO plan by Cigna Health and Life Insurance Company.

Locations

Cigna Connect 2500 ($0 Telehealth) is offered in the following counties.

Plan Overview

This is a plan overview for 2022 version of Cigna Connect 2500 ($0 Telehealth) 13401PA0010015.
Insurer: Cigna Health and Life Insurance Company
Network Type: EPO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 13401PA0010015

Cost-Sharing Overview

Cigna Connect 2500 ($0 Telehealth) offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Cigna Connect 2500 ($0 Telehealth)?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Cigna Connect 2500 ($0 Telehealth) offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Diabetes, Pregnancy, High Blood Pressure & High Cholesterol
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Cigna Connect 2500 ($0 Telehealth) covers when you are out of the service area or out of the country.

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
National Network: No

Additional Benefits and Cost-Sharing

Cigna Connect 2500 ($0 Telehealth) includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Prosthetic Devices
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Outpatient Surgery Physician/Surgical Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Primary Care Visit to Treat an Injury or Illness
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Virtual medical visit with a Dedicated Virtual Care Physician is covered at No Charge. Refer to the policy for more information.
Rehabilitative Speech Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No30 Visit(s) per Year Same limits and coverage apply for habilitative services.Substantially Equal
Specialist Visit
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Includes Mental Health Office Visits and Substance Use Disorder Office Visits.
Outpatient Rehabilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No36 Visit(s) per Year Cardiac and Pulmonary Rehabilitation limited to 36 visits per year combined. Physical and Occupational Therapy limted to 30 visits per year combined. Benefit Period maximum amounts that apply to Physical Therapy do not apply to the treatment of lymphedema related to mastectomy. Speech Therapy- limited to 30 visits per year.Substantially Equal
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Preferred Brand Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Up to a 30 day supply at any participating pharmacy, or up to a 90 day supply at any participating 90 day retail pharmacy. You pay a copayment for each 30 day supply. Formulary Diabetic Supplies are covered at no charge. Refer to the prescription drug list for more information.
Eye Glasses for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No3 Item(s) per Year Up to age 19. Coverage limited to three pair of glasses/year (lenses and frames from pediatric selection). Coverage for the second and third pair of glasses dependent on a change in the member’s refractive state or to replace broken, damaged or lost glasses.Substantially Equal
Infusion Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Mental/Behavioral Health Inpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Major Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Acupuncture
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Weight Loss Programs
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Chemotherapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Basic Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Routine Foot Care
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Prenatal and Postnatal Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Dental Check-Up for Children
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Dental Only Plan Available
Allergy Testing
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Home Health Care Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No60 Visit(s) per Year Substantially Equal
Hospice Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Includes Respite care.
Bariatric Surgery
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
X-rays and Diagnostic Imaging
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Routine Eye Exam for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Up to age 19. As needed.Substantially Equal
Emergency Transportation/Ambulance
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Out-of-network: You pay the same level as In-network if it is an emergency as defined in your plan, otherwise Not covered.
Basic Dental Care – Child
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Dental Only Plan Available
Generic Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No 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 any participating pharmacy, or up to a 90 day supply at any participating 90 day retail pharmacy. You pay a copayment for each 30 day supply. Formulary Diabetic Supplies are covered at no charge. Refer to the prescription drug list for more information.
Radiation
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Imaging (CT/PET Scans, MRIs)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Dental Anesthesia
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No General anesthesia charges for dental care provided the Insured Person: (a) is a child 7 years of age or under; (b) is severely disabled; or (c) has a medical or behavioral condition which requires hospitalization or general anesthesia for dental care.Additional EHB Benefit
Substance Abuse Disorder Inpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Delivery and All Inpatient Services for Maternity Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Urgent Care Centers or Facilities
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Out-of-network: You pay the same level as In-network if it is an emergency as defined in your plan, otherwise Not covered.
Skilled Nursing Facility
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No120 Days per Year Substantially Equal
Routine Dental Services (Adult)
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Laboratory Outpatient and Professional Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Some laboratory tests for Diabetes are covered at no charge. Refer to the policy for more information.
Mental/Behavioral Health Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Infertility Treatment
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Artificial Insemination, with accompanying: simple sperm preparation; sperm washing; and/or thawing.
Specialty Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Including other high cost drugs. Up to a 30 day supply at any participating pharmacy, or up to a 30 day supply at any participating 90 day retail pharmacy.
Preventive Care/Screening/Immunization
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Non-Preferred Brand Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Up to a 30 day supply at any participating pharmacy, or up to a 90 day supply at any participating 90 day retail pharmacy.
Orthodontia – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Accidental Dental
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Covered- Limited to treatment for accidental injury to natural teeth within six months of the accidental injury.
Inpatient Physician and Surgical Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Hearing Aids
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No30 Visit(s) per Year Physical and Occupational Therapy limited to 30 visits per year combined. Benefit Period maximum amounts that apply to Physical Therapy do not apply to the treatment of lymphedema related to mastectomy. Same visits and coverage apply to habilitative services.Substantially Equal
Habilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No30 Visit(s) per Year Physical and Occupational Therapy limited to 30 visits per year combined. Benefit Period maximum amounts that apply to Physical Therapy do not apply to the treatment of lymphedema related to mastectomy. Speech Therapy- limited to 30 visits per year.Substantially Equal
Dialysis
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Benefit depends on place of treatment.
Cosmetic Surgery
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Reconstructive Surgery
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Transplant
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Lifesource Transplant Network travel maximum of $10,000 per insured person, per lifetime.
Major Dental Care – Child
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Dental Only Plan Available
Abortion for Which Public Funding is Prohibited
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Long-Term/Custodial Nursing Home Care
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Routine Eye Exam (Adult)
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Well Baby Visits and Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Chiropractic Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No20 Visit(s) per Year Substantially Equal
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Substance Abuse Disorder Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Emergency Room Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Out-of-network: You pay the same level as In-network if it is an emergency as defined in your plan, otherwise Not covered.
Inherited Metabolic Disorder – PKU
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Nutritional supplements or formulas as administered under the direction of a Physician for the therapeutic treatment of phenylketonuria (PKU), branched-chain ketonuria, galactosemia and homocystinuria.Additional EHB Benefit
Diabetes Education
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Treatment for Temporomandibular Joint Disorders
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Orthodontia – Child
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Dental Only Plan Available
Private-Duty Nursing
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Tier 2 Generic Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Up to a 30 day supply at any participating pharmacy, or up to a 90 day supply at any participating 90 day retail pharmacy. You pay a copayment for each 30 day supply.Additional EHB Benefit
Nutritional Counseling
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No6 Visit(s) per Year Substantially Equal
Durable Medical Equipment
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No

Free Preventive Services

There is no copayment or coinsurance for any of the following Cigna Connect 2500 ($0 Telehealth) preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Ready to sign up for Cigna Connect 2500 ($0 Telehealth)?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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