Cigna Simple Choice 7500

41921VA0020072
Expanded Bronze
EPO

Cigna Simple Choice 7500 is an Expanded Bronze EPO plan by Cigna Health and Life Insurance Company.

IMPORTANT: You are viewing the 2023 version of Cigna Simple Choice 7500 41921VA0020072. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Cigna Simple Choice 7500 is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Cigna Simple Choice 7500 41921VA0020072.
Insurer: Cigna Health and Life Insurance Company
Network Type: EPO
Metal Type: Expanded Bronze
HSA Eligible?: No
Plan ID: 41921VA0020072

Cost-Sharing Overview

Cigna Simple Choice 7500 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 Simple Choice 7500?

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 Simple Choice 7500 offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy
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 Simple Choice 7500 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 Services Only
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Emergency Services Only
National Network: No

Additional Benefits and Cost-Sharing

Cigna Simple Choice 7500 includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$50.00 100.00% Refer to the policy for more information about Virtual Care Services. In home visits by a Primary Care Physician are covered, refer to the policy for more information. Includes Mental Health Office Visits and Substance Use Disorder Office Visits.
Specialist Visit
Covered
$100.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$100.00 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
50.00% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
50.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
50.00% Coinsurance after deductible 100.00% Coverage for custodial care, inpatient respite care, home health aide services, and homemaker services given by or under the supervision of a registered nurse. Bereavement services, both before and after the member?s death. Services for the surviving members of the immediate family for up to one year after the member?s death. Immediate family means all family members covered by this policy.
Routine Dental Services (Adult)
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Covered
50.00% Coinsurance after deductible 100.00%16 Hours per Year Included under Home Health Care Benefit
Routine Eye Exam (Adult)
Urgent Care Centers or Facilities
Covered
$75.00 $75.00 Out-of-network: You pay the same level as In-network if it is an emergency as defined in your plan, otherwise Not covered.
Home Health Care Services
Covered
50.00% Coinsurance after deductible 100.00%100 Visit(s) per Year
Emergency Room Services
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible Out-of-network: You pay the same level as In-network if it is an emergency as defined in your plan, otherwise Not covered.
Emergency Transportation/Ambulance
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible Ground, Air and Water transport. Out-of-network: You pay the same level as In-network if it is an emergency as defined in your plan, otherwise Not covered.
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
50.00% Coinsurance after deductible 100.00% Inpatient Room and Board, Lab and X-ray, Operating Room, etc. Out-of-Network: Emergency Services covered at In-Network cost share until transferable to an In-Network Hospital; if transferred to a Non-Participating Hospital services will no longer be covered and you will be responsible for 100% of the charges.
Inpatient Physician and Surgical Services
Covered
50.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Cosmetic Surgery
Skilled Nursing Facility
Covered
50.00% Coinsurance after deductible 100.00%100 Days per Stay
Prenatal and Postnatal Care
Covered
50.00% Coinsurance after deductible 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
50.00% Coinsurance after deductible 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$50.00 100.00% Includes treatment in an outpatient department of a hospital and office visits, individual psychotherapy, group psychotherapy, psychological testing and medication management visits. Services may be received by a psychiatrist, psychologist, neuropsychologist, licensed clinical social worker (L.C.S.W.), clinical nurse specialist, licensed marriage and family therapist (L.M.F.T.), licensed professional counselor (L.P.C) or any agency licensed by the state to give these services that must be covered by law. This benefit applies to Mental Health Office Visits. All other Mental Health Outpatient Services are covered at the Outpatient professional services benefit. Please refer to the SBC for more information.
Mental/Behavioral Health Inpatient Services
Covered
50.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$50.00 100.00% Includes treatment in an outpatient department of a hospital and office visits, individual psychotherapy, group psychotherapy, psychological testing and medication management visits. Services may be received by a psychiatrist, psychologist, neuropsychologist, licensed clinical social worker (L.C.S.W.), clinical nurse specialist, licensed marriage and family therapist (L.M.F.T.), licensed professional counselor (L.P.C) or any agency licensed by the state to give these services that must be covered by law. This benefit applies to Substance Abuse Office Visits. All other Substance Abuse Outpatient Services are covered at the Outpatient professional services benefit. Please refer to the SBC for more information.
Substance Abuse Disorder Inpatient Services
Covered
50.00% Coinsurance after deductible 100.00%
Generic Drugs
Covered
$25.00 100.00% 30 day supply at any participating pharmacy or up to a 90 day supply at a 90 day retail pharmacy. Formulary Diabetic Supplies are covered at no charge. Refer to the prescription drug list for more information. You pay a copayment for each 30 day supply.
Preferred Brand Drugs
Covered
$50.00 Copay after deductible 100.00% 30 day supply at any participating pharmacy or up to a 90 day supply at a 90 day retail pharmacy. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30 day supply. Formulary Diabetic Supplies are covered at no charge. Refer to the prescription drug list for more information. After deductible, you pay a copayment for each 30 day supply.
Non-Preferred Brand Drugs
Covered
$100.00 Copay after deductible 100.00% 30 day supply at any participating pharmacy or up to a 90 day supply at a 90 day retail pharmacy. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30 day supply. Refer to the prescription drug list for more information. After deductible, you pay a copayment for each 30 day supply.
Specialty Drugs
Covered
$500.00 Copay after deductible 100.00% Including other high cost drugs. 30 day supply at any participating pharmacy or up to a 30 day supply at a 90 day retail pharmacy. Refer to the prescription drug list for more information. After deductible, you pay a copayment for each 30 day supply.
Outpatient Rehabilitation Services
Covered
$50.00 100.00% Physical Therapy and Occupational Therapy – 30 visits combined per year, Speech Therapy and Speech-Language Pathology (SLP) Services – 30 visits per year, Chiropractic/Osteopathic and Manipulation Therapy – 30 visits per year. These limits do not apply to the hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders.
Habilitation Services
Covered
$50.00 100.00% Physical Therapy and Occupational Therapy – 30 visits combined per year, Speech Therapy and Speech-Language Pathology (SLP) Services – 30 visits per year, Chiropractic/Osteopathic and Manipulation Therapy – 30 visits per year. These limits do not apply to the hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders.
Chiropractic Care
Covered
50.00% Coinsurance after deductible 100.00%30 Visit(s) per Year Chiropractic/Osteopathic and Manipulation Therapy. Visit limit applies separately to habilitative and rehabilitative services.
Durable Medical Equipment
Covered
50.00% Coinsurance after deductible 100.00% Includes orthotics and cochlear implants.
Hearing Aids
Imaging (CT/PET Scans, MRIs)
Covered
50.00% Coinsurance after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
0.00% 100.00% Routine physicals and other preventive services
Routine Foot Care
Acupuncture
Weight Loss Programs
Routine Eye Exam for Children
Covered
No Charge 100.00%1 Visit(s) per Year
Eye Glasses for Children
Covered
No Charge 100.00%1 Item(s) per Year Limited to 1 pair of glasses (lenses and frames from pediatric selection) per calendar year. Therapeutic Contact Lenses are covered for a one year supply, regardless of the contact lens type, including professional services, in lieu of frame and lenses (may not receive contact lenses and frames in same benefit year). Elective Contact Lenses are covered for one pair or a single purchase of a supply of contact lenses in lieu of lenses and frame benefit (may not receive contact lenses and frames in same benefit year), including the professional services.
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$50.00 100.00%30 Visit(s) per Year Speech Therapy and Speech-Language Pathology (SLP) Services. Visit Limit applies separately to habilitative and rehabilitative services. These limits do not apply to the hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$50.00 100.00% Physical Therapy and Occupational Therapy – 30 visits combined per year. Visit Limit applies separately to habilitative and rehabilitative services. These limits do not apply to the hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders.
Well Baby Visits and Care
Covered
No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
50.00% Coinsurance after deductible 100.00% Refer to the policy for more information regarding Diabetes.
X-rays and Diagnostic Imaging
Covered
50.00% Coinsurance after deductible 100.00%
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Orthodontia – Adult
Major Dental Care – Adult
Abortion for Which Public Funding is Prohibited
Transplant
Covered
50.00% Coinsurance after deductible 100.00% Lifesource Travel benefit – unlimited, per insured person, per transplant
Accidental Dental
Covered
50.00% Coinsurance after deductible 100.00% Treatment must begin within 12 months of injury. Dental appliances required to diagnose or treat an accidental injury to the teeth, and the repair of dental appliances damaged as a result of accidental injury to the jaw, mouth or face, are also covered.
Dialysis
Covered
50.00% Coinsurance after deductible 100.00% Benefit depends on place of treatment.
Allergy Testing
Covered
50.00% Coinsurance after deductible 100.00%
Chemotherapy
Covered
50.00% Coinsurance after deductible 100.00%
Radiation
Covered
50.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
No Charge 100.00% Including nutritional therapy
Prosthetic Devices
Covered
30.00% Coinsurance after deductible 100.00% External and internal, includes components. Coverage is also included for the repair, fitting, adjustments and replacement of a prosthetic device.
Infusion Therapy
Covered
50.00% Coinsurance after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
50.00% Coinsurance after deductible 100.00%
Nutritional Counseling
Covered
50.00% Coinsurance after deductible 100.00% Unlimited for diabetics and mental health/substance abuse diagnosis.
Reconstructive Surgery
Covered
50.00% Coinsurance after deductible 100.00%
Gender Affirming Care
Not Covered

Free Preventive Services

There is no copayment or coinsurance for any of the following Cigna Simple Choice 7500 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.

Additional Resources

Below are additional resources for Cigna Simple Choice 7500 including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Cigna Simple Choice 7500?

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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