Cigna Premier Medicare (HMO-POS)

Cigna
Cigna Premier Medicare (HMO-POS) H1415-021 Plan Details
3 out of 5 stars

Cigna Premier Medicare (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H1415-021.

$0.00
Monthly Premium

Cigna Premier Medicare (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H1415-021.

Cigna
Cigna Premier Medicare (HMO-POS) H1415-021 Plan Details
3 out of 5 stars

Cigna Premier Medicare (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H1415-021.

$0.00
Monthly Premium

Illinois Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $4500
Out-of-Network: N/A
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00
POS (Out-of-Network):

Doctor Office Visit:
Coinsurance for Medicare Covered Primary Care Office Visit 30%
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $35.00
Prior Authorization Required for Doctor Specialty Visit
Referral Required for Doctor Specialty Visit
Prior authorization required
POS (Out-of-Network):

Doctor Specialty Visit:
Coinsurance for Medicare Covered Physician Specialist Office Visit 30%
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$275.00 per day for days 1 to 7
$0.00 per day for days 8 to 90
Prior Authorization Required for Acute Hospital Services
Referral Required for Acute Hospital Services
Prior authorization required
Out-of-Network:
Coinsurance for Acute Hospital Services per Stay 30%
Urgent Care
Copayment for Urgent Care $30.00
Copayment for Medicare Covered Urgent Care waived if you are admitted to hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $90.00
Maximum Plan Benefit of $50,000
Emergency Room Visit
Copayment for Emergency Care $90.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $90.00
Copayment for Worldwide Emergency Transportation $90.00
Maximum Plan Benefit of $50,000
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $260.00

Air Ambulance:
Coinsurance for Air Ambulance Services 20%

Please see Evidence of Coverage for Prior Authorization rules
Prior authorization required
POS (Out-of-Network):

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $260.00
Coinsurance for Medicare Covered Ambulance Services - Air 20%

Health Care Services and Medical Supplies

Cigna Premier Medicare (HMO-POS) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services
In-Network:
Copayment for Medicare-covered Chiropractic Services $15.00
Prior Authorization Required for Chiropractic Services
Referral Required for Chiropractic Services
Prior authorization required
POS (Out-of-Network):
Coinsurance for Medicare Covered Chiropractic Services 30%
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Coinsurance for Medicare-covered Diabetic Supplies 0% to 20%
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%
Prior Authorization Required for Diabetic Supplies and Services
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)
Prior authorization required
POS (Out-of-Network):
Coinsurance for Medicare Covered Diabetic Supplies and Services 30%
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment
Prior authorization required
POS (Out-of-Network):
Coinsurance for Medicare Covered Durable Medical Equipment 30%
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 to $50.00
Copayment for Medicare-covered Lab Services $0.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services
Referral Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0.00 to $200.00
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Referral Required for Outpatient Diag/Therapeutic Rad Services
Prior authorization required
POS (Out-of-Network):

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 30%
Coinsurance for Medicare Covered Lab Services 0% to 30%
Coinsurance for Medicare Covered Diagnostic Radiological Services 30%
Coinsurance for Medicare Covered Therapeutic Radiological Services 30%
Coinsurance for Medicare Covered Outpatient X-Ray Services 30%
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Prior authorization required
POS (Out-of-Network):
Coinsurance for Medicare Covered Home Health 30%
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$265.00 per day for days 1 to 7
$0.00 per day for days 8 to 90
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Out-of-Network:
Coinsurance for Psychiatric Hospital Services per Stay 30%
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $0.00
Copayment for Medicare-covered Group Sessions $0.00
Prior Authorization Required for Outpatient Mental Health Services
Prior authorization required
POS (Out-of-Network):
Coinsurance for Medicare Covered Individual Sessions 30%
Coinsurance for Medicare Covered Group Sessions 30%
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $240.00
Prior Authorization Required for Outpatient Hospital Services
Referral Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $240.00
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0.00 to $175.00
Prior Authorization Required for Ambulatory Surgical Center Services
Referral Required for Ambulatory Surgical Center Services
Prior authorization required
POS (Out-of-Network):

Outpatient Hospital and ASC Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 30%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 30%
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $35.00
Copayment for Medicare-covered Group Sessions $35.00
Prior Authorization Required for Outpatient Substance Abuse Services
Prior authorization required
POS (Out-of-Network):
Coinsurance for Medicare Covered Individual or Group Sessions 30%
Over-the-counter (OTC) Items
In-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $25.00 every three months
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $35.00
Referral Required for Podiatry Services
POS (Out-of-Network):
Coinsurance for Medicare Covered Podiatry Services 30%
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$188.00 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Prior authorization required
Out-of-Network:
Coinsurance for Skilled Nursing Facility Services per Stay 30%

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
In-Network:

Preventive Dental:
Copayment for Oral Exams $0.00 to $55.00
  • Maximum 4 visits every year
Copayment for Prophylaxis (Cleaning) $0.00 to $45.00
  • Maximum 2 visits every year
Copayment for Fluoride Treatment $0.00 to $15.00
  • Maximum 2 visits every year
Copayment for Dental X-Rays $0.00 to $81.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)

Comprehensive Dental:
Copayment for Medicare-covered Benefits $35.00
Copayment for Diagnostic Services $0.00
Copayment for Restorative Services $0.00 to $815.00
Copayment for Endodontics $38.00 to $675.00
Copayment for Periodontics $0.00 to $115.00
Copayment for Extractions $0.00
Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $0.00 to $970.00
Prior Authorization Required for Comprehensive Dental
Prior authorization required
POS (Out-of-Network):

Medicare Covered Dental Services:
Coinsurance for Medicare Covered Comprehensive Dental 30%

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0.00 to $35.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Copayment for Contact Lenses $0.00
Copayment for Eyeglasses (lenses and frames) $0.00
  • Maximum 1 Pair
Copayment for Eyeglass Lenses $0.00
  • Maximum 1 Pair
Copayment for Eyeglass Frames $0.00
  • Maximum 1 Pair
Copayment for Upgrades $0.00
Maximum Plan Benefit of $150.00 every year for all Non-Medicare covered eyewear
POS (Out-of-Network):

Medicare Covered Vision Services:
Coinsurance for Medicare Covered Eye Exams 30%
Coinsurance for Medicare Covered Eyewear 30%

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $35.00
Copayment for Routine Hearing Exams $0.00
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00
  • Maximum 1 visit every three years
Referral Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $0.00
  • Maximum 1 Hearing Aids every three years
Maximum Plan Benefit of $700.00 every three years per ear
A routine hearing exam should be performed prior to hearing aids being dispensed. Hearing aid devices do not include assisted listening devices, amplifiers or disposable devices.
POS (Out-of-Network):

Medicare Covered Hearing Services:
Coinsurance for Medicare Covered Hearing Exams 30%

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs
In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit
    POS (Out-of-Network):

    Medicare-covered Zero Dollar Preventive Services:
    Coinsurance for Medicare Covered Medicare-covered Preventive Services 30%