Cigna TotalCare Plus (HMO D-SNP)
Cigna TotalCare Plus (HMO D-SNP) H9725-013 Plan Details
Cigna TotalCare Plus (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Cigna
Plan ID: H9725-013
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$0.00
Monthly Premium
Cigna TotalCare Plus (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Cigna
Plan ID: H9725-013
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
Cigna TotalCare Plus (HMO D-SNP) H9725-013 Plan Details
Cigna TotalCare Plus (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Cigna
Plan ID: H9725-013
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
$0.00
Monthly Premium
North Carolina Counties Served
Transylvania
Henderson
Buncombe
Polk
Yancey
Avery
Mcdowell
Madison
Mitchell
Alleghany
Johnston
Union
Alexander
Mecklenburg
Cleveland
Rockingham
Rowan
Iredell
Orange
Guilford
Wake
Cabarrus
Forsyth
Burke
Lincoln
Randolph
Wilkes
Davie
Gaston
Alamance
Caldwell
Chatham
Durham
Yadkin
Catawba
Anson
Davidson
Stokes
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $8850 Out-of-Network: N/A |
| Initial Coverage Limit | $5030 |
| Catastrophic Coverage Limit | $8,000 |
| Primary Care Doctor Visit | 20% |
| Specialty Doctor Visit | 20% |
| Inpatient Hospital Care | Standard Medicare |
| Urgent Care | Copayment for Urgent Care $0.00 Copayment for Medicare Covered Urgent Care waived if you are admitted to hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Urgent Coverage $100.00 Maximum Plan Benefit of $50,000 |
| Emergency Room Visit | Copayment for Emergency Care $0.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $100.00 Copayment for Worldwide Emergency Transportation $100.00 Maximum Plan Benefit of $50,000 |
| Ambulance Transportation | Ambulance - Ground: 20% Ambulance - Air: 20% |
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 | 20% Routine Chiropractic (Supplemental): Not covered |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | If you’re managing diabetes, Cigna Healthcare makes it easier and more affordable to get monitoring and testing supplies. Your plan covers preferred brand diabetic supplies plus home delivery options. So you have less to worry about. Diabetic Supplies: $0 Diabetic Therapeutic Shoes or Inserts: 20% |
| Durable Medical Eqipment (DME) | 20% |
| 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 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 Copayment for Medicare-covered Therapeutic Radiological Services $0.00 Copayment for Medicare-covered X-Ray Services $0.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services Prior authorization required |
| Home Health Care | $0 Support for Caregivers of Enrollees: Not covered |
| Mental Health Inpatient Care | Standard Medicare |
| Mental Health Outpatient Care | Psychiatric-Individual: $0 Psychiatric-Group: $0 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services $0.00 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0.00 Prior Authorization Required for Ambulatory Surgical Center Services Prior authorization required |
| Outpatient Substance Abuse Care | 20% |
| Over-the-counter (OTC) Items | $265 every three months Delivered via Cigna Health Today card |
| Podiatry Services | 20% |
| Skilled Nursing Facility Care | Standard Medicare |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network: Preventive Dental: Maximum Plan Allowance of $4000.00 every year for Preventive and Non-Medicare Covered Comprehensive combined Comprehensive Dental: Copayment for Medicare-covered Benefits $0.00 Maximum Plan Allowance of $4000.00 every year for Preventive and Non-Medicare Covered Comprehensive combined |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network: Eye Exams: Coinsurance for Medicare Covered Benefits $0.00 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 |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | 20% Fitting/Evaluation for Hearing Aids: $0 for one fitting evaluation for hearing aid every year Hearing Aids: Cost Sharing: |
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 |
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