Cigna TotalCare Plus (HMO D-SNP)

Cigna
Cigna TotalCare Plus (HMO D-SNP) H4513-034 Plan Details
5 out of 5 stars

Cigna TotalCare Plus (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Cigna.
Plan ID: H4513-034.

$0.00
Monthly Premium

Cigna TotalCare Plus (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Cigna.
Plan ID: H4513-034.

Cigna
Cigna TotalCare Plus (HMO D-SNP) H4513-034 Plan Details
5 out of 5 stars

Cigna TotalCare Plus (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Cigna.
Plan ID: H4513-034.

$0.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $0
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 0-20%
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit 20%
Prior Authorization Required for Doctor Specialty Visit
Prior authorization required
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$222.00 per day for days 1 to 10
$0.00 per day for days 11 to 90
Prior Authorization Required for Acute Hospital Services
Prior authorization required
Urgent Care
Copayment for Urgent Care 20%; up to $60
Coinsurance 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 20%

Air Ambulance:
Copayment for Air Ambulance Services 20%

Please see Evidence of Coverage for Prior Authorization rules
Prior authorization required

Health Care Services and Medical Supplies

Cigna TotalCare Plus (HMO D-SNP) 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%
Prior Authorization Required for Chiropractic Services
Prior authorization required
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Copayment for Medicare-covered Diabetic Supplies $0.00
Copayment 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
Durable Medical Eqipment (DME)
In-Network:
Copayment for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment
Prior authorization required
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests 0-20%
Copayment for Medicare-covered Lab Services 20%
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services 0-20%
Copayment for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services 20%
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Prior authorization required
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Prior authorization required
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$187.00 per day for days 1 to 10
$0.00 per day for days 11 to 90
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
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
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services 0-20%
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services 20%
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services 0-20%
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions 20%
Copayment for Medicare-covered Group Sessions 20%
Prior Authorization Required for Outpatient Substance Abuse Services
Prior authorization required
Over-the-counter (OTC) Items
In-Network:

Over-The-Counter (OTC) Items:
Maximum Plan Benefit of $225.00 every three months
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services 20%
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

Dental Benefits

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

Coverage Cost
Dental Care
In-Network:

Preventive Dental:
Maximum Plan Allowance of $3000.00 every year for Preventive and Non-Medicare Covered Comprehensive combined

Comprehensive Dental:
Copayment for Medicare-covered Benefits 20%
Maximum Plan Allowance of $3000.00 every year for Preventive and Non-Medicare Covered Comprehensive combined
Prior Authorization Required for Comprehensive Dental
Prior authorization required

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 0-20%
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Copayment for Medicare-Covered Benefits 20%
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 $400.00 every year for all Non-Medicare covered eyewear

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 20%
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

Hearing Aids:
Maximum Plan Benefit of $1400.00 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.

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

    Prescription Drug Costs and Coverage

    The Cigna TotalCare Plus (HMO D-SNP) plan offers the following prescription drug coverage, with an annual drug deductible of $0 per year.

    Coverage
    Cost
    Coverage & Cost
    Annual Drug Deductible $0
    Preferred Generic
    • Standard retail $0.00
    • Preferred cost-share mail order $0.00
    • Standard mail order $0.00
    Generic
    • Standard retail $0.00
    • Preferred cost-share mail order $0.00
    • Standard mail order $0.00
    Preferred Brand
    • Standard retail $0.00
    • Preferred cost-share mail order $0.00
    • Standard mail order $0.00
    Annual Drug Deductible $0
    Preferred Generic
    • Standard retail N/A
    • Preferred cost-share mail order N/A
    • Standard mail order N/A
    Generic
    • Standard retail N/A
    • Preferred cost-share mail order N/A
    • Standard mail order N/A
    Preferred Brand
    • Standard retail N/A
    • Preferred cost-share mail order N/A
    • Standard mail order N/A
    Annual Drug Deductible $0
    Preferred Generic
    • Standard retail $0.00
    • Preferred cost-share mail order $0.00
    • Standard mail order $0.00
    Generic
    • Standard retail $0.00
    • Preferred cost-share mail order $0.00
    • Standard mail order $0.00
    Preferred Brand
    • Standard retail $0.00
    • Preferred cost-share mail order $0.00
    • Standard mail order $0.00