Cigna Simple Choice 7500 - 81808UT0020020 Health Insurance Plan
Cigna Health and Life Insurance Company health insurance plan with the Plan ID 81808UT0020020. The plan is called Cigna Simple Choice 7500.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.18% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.82% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
| Health Insurance Plan ID | 81808UT0020020 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Utah | ||||||||||||||||||
| Health Insurance Issuer | Cigna Health and Life Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 81808UT0020020-00 | ||||||||||||||||||
| Provider Network(s) | ['UTN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 22 Oct 2024 06:47 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 81808UT0020020-00 Standard On Exchange Plan - 81808UT0020020-01 |
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| Last Plan Update Date | Thu, 23 Feb 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 22 Oct 2024 06:47 GMT |
Benefits of Cigna Simple Choice 7500 Health Insurance Plan, 81808UT0020020-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
NO | ||
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Autism Spectrum Disorders
Includes ABA Therapy. Prior authorization required. |
YES | $50.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
|
NO | ||
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | No Charge |
100.00% |
| Dialysis
Benefit depends on place of treatment. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
Out-of-network: You pay the same level as in-network if it is an emergency as defined in your plan, otherwise not covered. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
Out-of-network: You pay the same level as in-network if it is an emergency as defined in your plan, otherwise not covered. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year For children up to age 19. 1 pair of glasses (lenses and frames from pediatric selection) per 12 month period. Contact lenses are covered for one pair or a single purchase of a supply of contact lenses, including professional services, in lieu of frame and lenses. |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
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 a 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. |
YES | $25.00 |
100.00% |
| Habilitation Services
Services for physical therapy, occupational therapy and speech therapy have a maximum of 20 visits per calendar year, all services combined. |
YES | $50.00 |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 30.0 Visit(s) per Year |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Hospice Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Inherited Metabolic Disorder - PKU
|
YES | $50.00 |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
Some laboratory tests for Diabetes are covered at no charge. Refer to the policy for more information. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
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. |
YES | $50.00 |
100.00% |
| Non-Preferred Brand Drugs
Up to a 30 day supply at any Participating Pharmacy or up to a 90 day supply at a 90 day Retail Pharmacy. After deductible, you pay a copayment for each 30 day supply. |
YES | $100.00 Copay after deductible |
100.00% |
| Nutritional Counseling
|
NO | ||
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $100.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Services for physical therapy, occupational therapy and speech therapy have a maximum of 20 visits per calendar year, all services combined. Services for cardiac and pulmonary rehabilitation have a maximum of 5 visits per calendar year, all services combined. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
Up to a 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. After deductible, you pay a copayment for each 30 day supply. |
YES | $50.00 Copay after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Refer to the policy for more information about Virtual Care Services. Includes Mental Health Office Visits and Substance Use Disorder Office Visits. |
YES | $50.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Services for physical therapy, occupational therapy and speech therapy have a maximum of 20 visits per calendar year, all services combined. |
YES | $50.00 |
100.00% |
| Rehabilitative Speech Therapy
Services for speech therapy have a 20 visit limit per calendar year combined with physical and occupational therapy. |
YES | $50.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year For children up to age 19. |
YES | No Charge |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 30.0 Days per Year |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $100.00 |
100.00% |
| Specialty Drugs
Including other high cost drugs. Up to a 30 day supply at any Participating Pharmacy or up to a 30 day supply at a 90 day Retail Pharmacy. After deductible, you pay a copayment for each 30 day supply. |
YES | $500.00 Copay after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
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. |
YES | $50.00 |
100.00% |
| Transplant
Lifesource Travel benefit - unlimited, per insured person, per transplant |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
Out-of-network: You pay the same level as in-network if it is an emergency as defined in your plan, otherwise not covered. |
YES | $75.00 |
$75.00 |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Cigna Simple Choice 7500 Health Insurance Plan Variant 81808UT0020020-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.641786747 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Bronze Off Exchange Plan |
| Dental Only Plan | No |
| Design Type | Design 1 |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy |
| EHB Percent of Total Premium | 1 |
| First Tier Utilization | 100% |
| Formulary ID | UTF015 |
| Formulary URL | URL |
| HIOS Product ID | 81808UT002 |
| Import Date | 2/23/2023 20:01 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | New |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 81808 |
| Issuer Marketplace Marketing Name | Cigna Healthcare |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Expanded Bronze |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | UTN001 |
| Out of Country Coverage | No |
| Out of Country Coverage Description | Emergency Services Only |
| Out of Service Area Coverage | No |
| Out of Service Area Coverage Description | Emergency Services Only |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 81808UT0020020-00 |
| Plan Marketing Name | Cigna Simple Choice 7500 |
| Plan Type | EPO |
| Plan Variant Marketing Name | Cigna Simple Choice 7500 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,500 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $7,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,000 |
| SBC Scenario, Having Diabetes, Deductible | $900 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $500 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,700 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | UTS001 |
| Source Name | SERFF |
| Plan ID | 81808UT0020020 |
| State Code | UT |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $15000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $7500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $7,500 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $18000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Cigna Simple Choice 7500 Health Insurance Plan, 81808UT0020020
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Cigna Simple Choice 7500, 81808UT0020020 Health Insurance Plan, 81808UT0020020
-
Does Cigna Simple Choice 7500 Health Insurance Plan, 81808UT0020020 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (81808UT0020020) Health Insurance Plan, Variant (81808UT0020020-00) offer Disease Management Programs?
Does (81808UT0020020) Health Insurance Plan, Variant (81808UT0020020-00) have Out Of Country Coverage?
Does (81808UT0020020) Health Insurance Plan, Variant (81808UT0020020-00) have Out of Service Area Coverage?
Does (81808UT0020020) Health Insurance Plan, Variant (81808UT0020020-00) offer Disease Management Programs?
Does Cigna Simple Choice 7500 Health Insurance Plan, Variant (81808UT0020020-00) offer Disease Management Programs for Asthma?
Does Cigna Simple Choice 7500 Health Insurance Plan, Variant (81808UT0020020-00) offer Disease Management Programs for Heart disease?
Does Cigna Simple Choice 7500 Health Insurance Plan, Variant (81808UT0020020-00) offer Disease Management Programs for Diabetes?
Does Cigna Simple Choice 7500 Health Insurance Plan, Variant (81808UT0020020-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Cigna Simple Choice 7500 Health Insurance Plan, Variant (81808UT0020020-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 22 Oct 2024 06:47 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API