Cigna Simple Choice 9100

94419IN0010005
Bronze
EPO

Cigna Simple Choice 9100 is a Bronze EPO plan by Cigna Healthcare.

IMPORTANT: You are viewing the 2023 version of Cigna Simple Choice 9100 94419IN0010005. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Cigna Simple Choice 9100 is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Cigna Simple Choice 9100 94419IN0010005.
Insurer: Cigna Healthcare
Network Type: EPO
Metal Type: Bronze
HSA Eligible?: No
Plan ID: 94419IN0010005

Cost-Sharing Overview

Cigna Simple Choice 9100 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 9100?

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 9100 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 9100 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 9100 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
No Charge after deductible 100.00% Refer to the policy for more information about Virtual Care Services.
Specialist Visit
Covered
No Charge after deductible 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
No Charge after deductible 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
No Charge after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
No Charge after deductible 100.00%
Hospice Services
Covered
No Charge after deductible 100.00%
Routine Dental Services (Adult)
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Covered
No Charge after deductible 100.00%82 Visit(s) per Year
Routine Eye Exam (Adult)
Urgent Care Centers or Facilities
Covered
No Charge after deductible No Charge 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.
Home Health Care Services
Covered
No Charge after deductible 100.00%100 Visit(s) per Year Maximum does not include home infusion therapy or private duty nursing rendered in the home.
Emergency Room Services
Covered
No Charge after deductible No Charge 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
No Charge after deductible No Charge 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.
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
No Charge after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
No Charge after deductible 100.00%
Bariatric Surgery
Cosmetic Surgery
Skilled Nursing Facility
Covered
No Charge after deductible 100.00%90 Days per Year
Prenatal and Postnatal Care
Covered
No Charge after deductible 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
No Charge after deductible 100.00%
Mental/Behavioral Health Outpatient Services
Covered
No Charge after deductible 100.00%
Mental/Behavioral Health Inpatient Services
Covered
No Charge after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
No Charge after deductible 100.00%
Substance Abuse Disorder Inpatient Services
Covered
No Charge after deductible 100.00%
Generic Drugs
Covered
No Charge after deductible 100.00% Up to a 30 day supply at any designated pharmacy, or up to a 90 day supply at any designated 90 day retail pharmacy. Formulary Diabetic Supplies are covered at no charge. Refer to the prescription drug list for more information.
Preferred Brand Drugs
Covered
No Charge after deductible 100.00% Up to a 30-day supply at any designated pharmacy or up to a 90-day supply at any designated 90 day retail pharmacy. Formulary Diabetic Supplies are covered at no charge. Refer to the prescription drug list for more information.
Non-Preferred Brand Drugs
Covered
No Charge after deductible 100.00% Up to a 30 day supply at any designated pharmacy, or up to a 90 day supply at any designated 90 day retail pharmacy.
Specialty Drugs
Covered
No Charge after deductible 100.00% Including other high cost drugs. Up to a 30-day supply at any designated pharmacy or up to a 30-day supply at any designated 90 day retail pharmacy.
Outpatient Rehabilitation Services
Covered
No Charge after deductible 100.00% Physical therapy limited to 20 visits per year; Occupational therapy limited to 20 visits per year; Speech therapy limited to 20 visits per year. Maximums for Habilitative Services do not reduce maximums for Rehabilitation Services. Maximum does not apply to services for treatment of Autism Spectrum Disorders. Cardiac Rehabilitation limited to 36 visits per year. Pulmonary Rehabilitation limited to 20 visits per year.
Habilitation Services
Covered
No Charge after deductible 100.00% Physical therapy limited to 20 visits per year; Occupational therapy limited to 20 visits per year; Speech therapy limited to 20 visits per year. Maximums for Rehabilitative Services do not reduce maximums for Habilitative Services. Maximum does not apply to services for treatment of Autism Spectrum Disorders.
Chiropractic Care
Covered
No Charge after deductible 100.00%12 Visit(s) per Year Includes Osteopathic/Manipulation Therapy. Maximum does not apply to services for treatment of Autism Spectrum Disorders
Durable Medical Equipment
Covered
No Charge after deductible 100.00% Maximum of 1 wig per Insured Person, per year.
Hearing Aids
Imaging (CT/PET Scans, MRIs)
Covered
No Charge after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
0.00% 100.00%
Routine Foot Care
Acupuncture
Weight Loss Programs
Routine Eye Exam for Children
Covered
No Charge 100.00%1 Visit(s) per Year Children up to age 19, through the end of their birth month.
Eye Glasses for Children
Covered
No Charge 100.00%1 Item(s) per Year Children up to age 19, through the end of their birth month. 1 pair of glasses (lenses and frames from pediatric selection) per 12 month period. Contact lenses for Children – One pair or one box per eye of contact lenses, including professional services ? in lieu of lenses and frame benefit, (may not receive contact lenses and frames in same benefit year).
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
No Charge after deductible 100.00%20 Visit(s) per Year Limited to 20 visits per year. Maximums for Habilitative Services do not reduce maximums for rehabilitative services. Maximum does not apply to services for treatment of Autism Spectrum Disorders.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
No Charge after deductible 100.00% Limited to 20 visits per year for Occupational therapy and 20 visits per year for Physical therapy. Maximums for Habilitative Services do not reduce maximums for rehabilitative services. Maximum does not apply to services for treatment of Autism Spectrum Disorders.
Well Baby Visits and Care
Covered
No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
No Charge after deductible 100.00% Refer to the policy for more information regarding Diabetes.
X-rays and Diagnostic Imaging
Covered
No Charge 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
No Charge after deductible 100.00% Lifesource Travel maximum of $10,000 per transplant. Includes coverage for unrelated donor search services up to $30,000 per transplant; prior authorization required.
Accidental Dental
Covered
No Charge after deductible 100.00% Limited to treatment for accidental injury to natural teeth within 12 months of the accidental injury. Anesthesia and hospital charges for dental care, for a member less than 19 years of age or a member who is physically or mentally disabled, are covered if the member requires dental treatment to be given in a hospital or outpatient ambulatory surgical facility. The indications for General Anesthesia, as published in the reference manual of the American Academy of Pediatric Dentistry, should be used to determine whether performing dental procedures is necessary to treat the member?s condition under general anesthesia. This coverage does not apply to treatment for TMJ.
Dialysis
Covered
No Charge after deductible 100.00% Benefit depends on place of treatment.
Allergy Testing
Covered
No Charge after deductible 100.00%
Chemotherapy
Covered
No Charge after deductible 100.00%
Radiation
Covered
No Charge after deductible 100.00%
Diabetes Education
Covered
No Charge 100.00%
Prosthetic Devices
Covered
No Charge after deductible 100.00%
Infusion Therapy
Covered
No Charge after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
No Charge after deductible 100.00%
Nutritional Counseling
Covered
No Charge after deductible 100.00%
Reconstructive Surgery
Covered
No Charge after deductible 100.00%
Gender Affirming Care

Free Preventive Services

There is no copayment or coinsurance for any of the following Cigna Simple Choice 9100 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 9100 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 9100?

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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