Cigna True Choice Medicare (PPO)

Cigna
Cigna True Choice Medicare (PPO) H7849-020 Plan Details
Plan too new to be measured

Cigna True Choice Medicare (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H7849-020.

$0.00
Monthly Premium

Cigna True Choice Medicare (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H7849-020.

Cigna
Cigna True Choice Medicare (PPO) H7849-020 Plan Details
Plan too new to be measured

Cigna True Choice Medicare (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H7849-020.

$0.00
Monthly Premium

Georgia Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $195
Out of Pocket Max In-Network: $7400
Out-of-Network: 11000
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 to $5.00
Out-of-Network:

Doctor Office Visit:
Copayment for Medicare Covered Primary Care Office Visit $40.00
Specialty Doctor Visit
In-Network:

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

Doctor Specialty Visit:
Copayment for Medicare Covered Physician Specialist Office Visit $55.00
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$375.00 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 35%
Urgent Care
Copayment for Urgent Care $55.00
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 $245.00

Air Ambulance:
Coinsurance for Air Ambulance Services 20%

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

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $245.00
Coinsurance for Medicare Covered Ambulance Services - Air 20%

Health Care Services and Medical Supplies

Cigna True Choice Medicare (PPO) 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
Prior authorization required
Out-of-Network:
Copayment for Medicare Covered Chiropractic Services $55.00
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
Out-of-Network:
Coinsurance for Medicare Covered Diabetic Supplies and Services 35%
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Durable Medical Equipment 35%
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 $95.00
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 $225.00
Copayment for Medicare-covered Therapeutic Radiological Services $60.00
Copayment for Medicare-covered X-Ray Services $0.00 to $25.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Prior authorization required
Out-of-Network:

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 35%
Coinsurance for Medicare Covered Lab Services 0% to 35%
Coinsurance for Medicare Covered Diagnostic Radiological Services 35%
Coinsurance for Medicare Covered Therapeutic Radiological Services 35%
Coinsurance for Medicare Covered Outpatient X-Ray Services 35%
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Home Health 35%
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$595.00 per day for days 1 to 3
$0.00 per day for days 4 to 90
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Out-of-Network:
Coinsurance for Psychiatric Hospital Services per Stay 35%
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
Out-of-Network:
Copayment for Medicare Covered Individual Sessions $55.00
Copayment for Medicare Covered Group Sessions $55.00
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $375.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $375.00
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0.00 to $325.00
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
Out-of-Network:

Outpatient Hospital and ASC Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 35%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 35%
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
Out-of-Network:
Copayment for Medicare Covered Individual or Group Sessions $55.00
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
Out-of-Network:

Over-The-Counter (OTC) Items:
Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $25.00
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $35.00
Out-of-Network:
Copayment for Medicare Covered Podiatry Services $55.00
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 35%

Dental Benefits

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

Coverage Cost
Dental Care
In-Network:

Preventive Dental:
Maximum Plan Allowance of $900.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined

Comprehensive Dental:
Copayment for Medicare-covered Benefits $35.00
Maximum Plan Allowance of $900.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined
Prior Authorization Required for Comprehensive Dental
Prior authorization required
Out-of-Network:

Medicare Covered Dental Services:
Copayment for Medicare Covered Comprehensive Dental $55.00
Non-Medicare Covered Dental Services:
Copayment for Non-Medicare Covered Preventive Dental $0.00
Copayment for Non-Medicare Covered Comprehensive Dental $0.00

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 $100.00 every year for all Non-Medicare covered eyewear for in and out of network services combined
Out-of-Network:

Medicare Covered Vision Services:
Copayment for Medicare Covered Eye Exams $0.00 to $55.00
Coinsurance for Medicare Covered Eyewear 35%
Non-Medicare Covered Vision Services:
Coinsurance for Non-Medicare Covered Eye Exams 35%
Copayment for Non-Medicare Covered Eyewear $0.00

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
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00
  • Maximum 1 visit every three years

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 for in and out of network services 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.
Out-of-Network:

Medicare Covered Hearing Services:
Copayment for Medicare Covered Hearing Exams $55.00
Non-Medicare Covered Hearing Services:
Coinsurance for Non-Medicare Covered Hearing Exams 35%
Copayment for Non-Medicare Covered Hearing Aids $0.00

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
    Out-of-Network:

    Medicare-covered Zero Dollar Preventive Services:
    Copayment for Medicare Covered Medicare-covered Preventive Services $0.00

    Prescription Drug Costs and Coverage

    The Cigna True Choice Medicare (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $195 (excludes Tiers 1, 2 and 3) per year.

    Coverage
    Cost
    Coverage & Cost
    Annual Drug Deductible $195 (excludes Tiers 1, 2 and 3)
    Preferred Generic
    • Preferred retail $3.00
    • Standard retail $8.00
    • Preferred mail order $3.00
    • Standard mail order $8.00
    Generic
    • Preferred retail $12.00
    • Standard retail $17.00
    • Preferred mail order $12.00
    • Standard mail order $17.00
    Preferred Brand
    • Preferred retail $42.00
    • Standard retail $47.00
    • Preferred mail order $42.00
    • Standard mail order $47.00
    Annual Drug Deductible $195 (excludes Tiers 1, 2 and 3)
    Preferred Generic
    • Preferred retail $6.00
    • Standard retail $16.00
    • Preferred mail order $6.00
    • Standard mail order $16.00
    Generic
    • Preferred retail $24.00
    • Standard retail $34.00
    • Preferred mail order $24.00
    • Standard mail order $34.00
    Preferred Brand
    • Preferred retail $84.00
    • Standard retail $94.00
    • Preferred mail order $84.00
    • Standard mail order $94.00
    Annual Drug Deductible $195 (excludes Tiers 1, 2 and 3)
    Preferred Generic
    • Preferred retail $7.50
    • Standard retail $24.00
    • Preferred mail order $0.00
    • Standard mail order $24.00
    Generic
    • Preferred retail $30.00
    • Standard retail $51.00
    • Preferred mail order $0.00
    • Standard mail order $51.00
    Preferred Brand
    • Preferred retail $126.00
    • Standard retail $141.00
    • Preferred mail order $126.00
    • Standard mail order $141.00