Cigna Premier Medicare (HMO-POS)
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) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Cigna.
Plan ID: H4513-036.
Tennessee Counties Served
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 |
|