Cigna Premier Medicare (HMO-POS)
Cigna Premier Medicare (HMO-POS) H4513-036 Plan Details
Cigna Premier Medicare (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Cigna.
Plan ID: H4513-036.
$55.00
Monthly Premium
Cigna Premier Medicare (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Cigna.
Plan ID: H4513-036.
Cigna Premier Medicare (HMO-POS) H4513-036 Plan Details
Cigna Premier Medicare (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Cigna.
Plan ID: H4513-036.
$55.00
Monthly Premium
Tennessee Counties Served
Bedford
Benton
Bledsoe
Cannon
Bradley
Carroll
Cheatham
Chester
Clay
Coffee
Crockett
Cumberland
Davidson
Decatur
Dekalb
Dickson
Fayette
Fentress
Gibson
Giles
Grundy
Hamilton
Hardeman
Hardin
Haywood
Henderson
Hickman
Houston
Humphreys
Jackson
Lauderdale
Lawrence
Lewis
Lincoln
Macon
Madison
Marion
Marshall
Maury
Mcnairy
Montgomery
Moore
Overton
Perry
Pickett
Polk
Putnam
Robertson
Rutherford
Sequatchie
Shelby
Smith
Stewart
Sumner
Tipton
Trousdale
Van Buren
Warren
Wayne
White
Williamson
Wilson
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $200 |
| Out of Pocket Max |
In-Network: $6700 Out-of-Network: N/A |
| Initial Coverage Limit | $4660 |
| Catastrophic Coverage Limit | $7,400 |
| 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 $30.00 Prior Authorization 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: $300.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 Prior Authorization 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 $95.00 Maximum Plan Benefit of $50,000 |
| Emergency Room Visit | Copayment for Emergency Care $95.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $95.00 Copayment for Worldwide Emergency Transportation $95.00 Maximum Plan Benefit of $50,000 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $230.00 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 $230.00 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 $20.00 Prior Authorization 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: Copayment for Medicare-covered Diabetic Supplies $0.00 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 $150.00 Copayment for Medicare-covered Lab Services $0.00 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0.00 to $150.00 Copayment for Medicare-covered Therapeutic Radiological Services $30.00 Copayment for Medicare-covered X-Ray Services $0.00 to $50.00 Prior Authorization 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 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: $300.00 per day for days 1 to 5 $0.00 per day for days 6 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 $300.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $200.00 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0.00 to $225.00 Prior Authorization 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 $30.00 Copayment for Medicare-covered Group Sessions $30.00 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: Maximum Plan Benefit of $60.00 every three months Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $30.00 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 $196.00 per day for days 21 to 61 $0.00 per day for days 62 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: Maximum Plan Allowance of $1500.00 every year for Preventive and Non-Medicare Covered Comprehensive combined Comprehensive Dental: Copayment for Medicare-covered Benefits $30.00 Maximum Plan Allowance of $1500.00 every year for Preventive and Non-Medicare Covered Comprehensive combined 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 $30.00 Copayment for Routine Eye Exams $0.00
Eyewear: Copayment for Medicare-Covered Benefits $0.00 Copayment for Contact Lenses $0.00 Copayment for Eyeglasses (lenses and frames) $0.00
Maximum Plan Benefit of $300.00 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 $30.00 Copayment for Routine Hearing Exams $0.00
Hearing Aids: Maximum Plan Benefit of $2500.00 every three years both ears combined 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:
Yearly "Wellness" visit POS (Out-of-Network): Medicare-covered Zero Dollar Preventive Services: Coinsurance for Medicare Covered Medicare-covered Preventive Services 30% |
Prescription Drug Costs and Coverage
The Cigna Premier Medicare (HMO-POS) plan offers the following prescription drug coverage, with an annual drug deductible of $200 (excludes Tiers 1, 2 and 3) per year.
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual Drug Deductible | $200 (excludes Tiers 1, 2 and 3) |
| Preferred Generic |
|
| Generic |
|
| Preferred Brand |
|
| Annual Drug Deductible | $200 (excludes Tiers 1, 2 and 3) |
| Preferred Generic |
|
| Generic |
|
| Preferred Brand |
|
| Annual Drug Deductible | $200 (excludes Tiers 1, 2 and 3) |
| Preferred Generic |
|
| Generic |
|
| Preferred Brand |
|
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