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
HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
$51.00
Monthly Premium
Cigna Premier Medicare (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Cigna
Plan ID: H4513-036
HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
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
HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
$51.00
Monthly Premium
Tennessee Counties Served
Smith
Dekalb
Houston
Lewis
Coffee
Clay
Cumberland
Dickson
Perry
Cannon
Bedford
Marshall
Stewart
Macon
Hickman
Jackson
Lincoln
Giles
Humphreys
Maury
Wayne
Warren
Van Buren
Moore
Fentress
Lawrence
Putnam
Overton
White
Pickett
Trousdale
Mcnairy
Shelby
Benton
Madison
Crockett
Haywood
Hardeman
Fayette
Chester
Lauderdale
Gibson
Decatur
Hardin
Henderson
Davidson
Hamilton
Polk
Grundy
Marion
Bledsoe
Bradley
Sequatchie
Tipton
Cheatham
Montgomery
Robertson
Wilson
Williamson
Rutherford
Sumner
Carroll
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $6150 Out-of-Network: N/A |
| Initial Coverage Limit | $2000 |
| Catastrophic Coverage Limit | $2,000 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 Out-of-Network: Doctor Office Visit Services: Coinsurance for Primary Care Office Visit 40% |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $30 Prior Authorization Required for Doctor Specialty Visit Out-of-Network: Doctor Specialty Visit Services: Coinsurance for Physician Specialist Office Visit 40% Prior authorization required |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $295 per day for days 1 to 6 $0 per day for days 7 to 90 Prior Authorization Required for Acute Hospital Services In some instances, a readmission policy may apply in which the benefit will continue from original admission. Prior authorization required |
| Urgent Care | Copayment for Urgent Care $30 Copayment for Medicare Covered Urgent Care waived if you are admitted to hospital within 2 hours Worldwide Coverage: Copayment for Worldwide Urgent Coverage $125 Maximum Plan Benefit of $50,000 |
| Emergency Room Visit | Copayment for Emergency Care $125 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $125 Copayment for Worldwide Emergency Transportation $125 Maximum Plan Benefit of $50,000 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $270 Air Ambulance: Coinsurance for Air Ambulance Services 20% Prior Authorization Required for Air Ambulance Out-of-Network: Ambulance Services: Copayment for Ambulance Services - Ground $270 Coinsurance for Ambulance Services - Air 20% Prior authorization required |
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 Prior Authorization Required for Chiropractic Services Out-of-Network: Medicare Covered Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 40% Prior authorization required |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Copayment for Medicare-covered Diabetic Supplies $0 Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20% Out-of-Network: Medicare Covered Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies 40% Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 40% |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization Required for Durable Medical Equipment Out-of-Network: Medicare Covered Durable Medical Equipment Services: Coinsurance for Medicare Covered Durable Medical Equipment 40% 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 to $150 Copayment for Medicare-covered Lab Services $0 to $50 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Minimum for EKG. Maximum for all other diagnostic procedures and tests. Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0 to $200 Copayment for Medicare-covered Therapeutic Radiological Services $30 Copayment for Medicare-covered X-Ray Services $0 to $50 If multiple test types (e.g. CT and PET) are performed on the same day, multiple copayments will apply. If multiple tests of the same type (e.g. CT scan of the head and CT scan of the chest) are performed on the same day, one copayment will apply. Out-of-Network: Medicare Covered Diagnostic Procedures/Tests Services: Coinsurance for Medicare Covered Diagnostic Procedures/Tests 40% Coinsurance for Medicare Covered Lab Services 40% Coinsurance for Medicare Covered Diagnostic Radiological Services 40% Coinsurance for Medicare Covered Therapeutic Radiological Services 40% Coinsurance for Medicare Covered Outpatient X-Ray Services 40% Minimum for EKG. Maximum for all other diagnostic procedures and tests. Prior authorization required |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services Out-of-Network: Medicare Covered Home Health Services: Coinsurance for Medicare Covered Home Health 40% Prior authorization required |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $295 per day for days 1 to 6 $0 per day for days 7 to 90 Prior Authorization Required for Psychiatric Hospital Services In some instances, a readmission policy may apply in which the benefit will continue from original admission. Prior authorization required |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $0 Copayment for Medicare-covered Group Sessions $0 Out-of-Network: Medicare Covered Mental Health Services: Coinsurance for Medicare Covered Individual Sessions 40% Coinsurance for Medicare Covered Group Sessions 40% |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $295 Prior Authorization Required for Outpatient Hospital Services Minimum for any surgical procedures (e.g. polyp removal) during a colorectal screening. Maximum for all other outpatient services not provided in an Ambulatory Surgical Center. Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $295 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 to $275 Prior Authorization Required for Ambulatory Surgical Center Services Minimum for any surgical procedures (e.g. polyp removal) during a colorectal screening. Maximum for all other Ambulatory Surgical Center (ASC) services. Out-of-Network: Medicare Covered Outpatient Hospital Services: Coinsurance for Medicare Covered Outpatient Hospital Services 40% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 40% Minimum for any surgical procedures (e.g. polyp removal) during a colorectal screening. Maximum for all other outpatient services not provided in an Ambulatory Surgical Center. Prior authorization required |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $30 Copayment for Medicare-covered Group Sessions $30 Prior Authorization Required for Outpatient Substance Abuse Services Out-of-Network: Medicare Covered Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual Sessions 40% Coinsurance for Medicare Covered Group Sessions 40% Prior authorization required |
| Over-the-counter (OTC) Items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0
Catalog orders limited to one per member per month. Exceptions may apply. |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $30 Out-of-Network: Medicare Covered Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 40% |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $214 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services In some instances, a readmission policy may apply in which the benefit will continue from original admission. Prior authorization required |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network: Preventive Dental: Copayment for Office Visit $30 Prior Authorization Required for Preventive Dental Comprehensive Dental: Copayment for Non-routine Services $0 Copayment for Diagnostic Services $0 Copayment for Restorative Services $0 Copayment for Endodontics $0 Copayment for Periodontics $0 Copayment for Extractions $0 Maximum Plan Benefit of $1,600 every year Out-of-Network: Medicare Covered Preventive Dental Services: Coinsurance for Medicare Covered Preventive Dental 40% 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 to $30 Copayment for Routine Eye Exams $0
Eyewear: Copayment for Medicare-Covered Benefits $0 Copayment for Contact Lenses $0 Copayment for Eyeglasses (lenses and frames) $0
Maximum Plan Benefit of $300 every year Corrective lenses, frames and contacts are covered once per year. The plan will not cover both corrective lenses/frames and contacts in the same benefit year. Out-of-Network: Medicare Covered Eye Exams Services: Coinsurance for Medicare Covered Eye Exams 40% Coinsurance for Medicare Covered Eyewear 40% |
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 Copayment for Routine Hearing Exams $0
Hearing Aids: Copayment for Hearing Aids $399 to $1800
Out-of-Network: Medicare Covered Hearing Exams Services: Coinsurance for Medicare Covered Hearing Exams 40% |
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 Out-of-Network: Medicare Covered Medicare-covered Preventive Services: Coinsurance for Medicare Covered Medicare-covered Preventive Services 40% |
