Cigna-HealthSpring Premier (HMO-POS)

Medicare Advantage Plan (Part C w/ RX)

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Plan Summary

Insurance Type
Medicare Advantage Plan (Part C w/ RX)
Insurance Provider
Leon Medical Centers, Cigna Healthspring
CMS Rating
Plan Type
HMO-POS
Annual Deductible
$0.00

What To Know About This Plan

  • This plan has health and drug coverage
  • This plan is available for 2015. see plan

Why We Like This Plan

  • has both Health and Drug Coverage
  • has been rated 5 stars by CMS
  • has no additional premium costs outside of your Medicare Part B premium
  • Primary care physician office visit copay of $10
  • was the 3rd best selling plan in Santa Rosa in 2014

Plan Details

Costs and Other Important Information

Plan Year:
2014
Optional Supplemental Benefits?
Yes
Choice of Doctors?
Plan Doctors Only (some exceptions)
Prescription Drugs Covered?
Yes
Out-Of-Pocket Spending Limit
$5,500 In-Network
Other Deductibles?
In Network: No. Out of Network: No
Health Plan Deductible
$0
Monthly Drug Plan Premium
$0.00
Monthly Health Plan Premium
$0.00

Benefits

Service
In Network
Out of Network
Inpatient Hospital Care
Days 1-6: $275 copay per day. Days 7-90: $0 copay per day. Point of Service: 30%
In Network: Days 1-6: $275 copay per day. Days 7-90: $0 copay per day. Point of Service: 30%
Inpatient Mental Health Care
Days 1-6: $245 copay per day. Days 7-90: $0 copay per day. Point of Service: 30%
In Network: Days 1-6: $245 copay per day. Days 7-90: $0 copay per day. Point of Service: 30%
Skilled Nursing Facility (SNF)
Days 1-5: $0 copay per day. Days 6-20: $25 copay per day. Days 21-100: $150 copay per day. Point of Service: 30%
In Network: Days 1-5: $0 copay per day. Days 6-20: $25 copay per day. Days 21-100: $150 copay per day. Point of Service: 30%
Home Health Care
$0Point of Service: Not Applicable
In Network: $0Point of Service: Not Applicable
Doctor Office Visits
$10 maximum per visit. Point of Service: 30% maximum per visit
In Network: $10 maximum per visit. Point of Service: 30% maximum per visit
Outpatient Services
$300 maximum per visit. Point of Service: 30% maximum per visit
In Network: $300 maximum per visit. Point of Service: 30% maximum per visit
Ambulance Services
$150 maximum or 20% maximum. Point of Service: $150 maximum or 20% maximum
In Network: $150 maximum or 20% maximum. Point of Service: $150 maximum or 20% maximum
Emergency Care
$65 maximum per visit. Point of Service: Not Applicable
In Network: $65 maximum per visit. Point of Service: Not Applicable
Durable Medical Equipment
20% maximum per item. Point of Service: 30% maximum per item
In Network: 20% maximum per item. Point of Service: 30% maximum per item
Kidney Disease and Conditions
20% maximum per visit. Point of Service: 30% maximum per visit
In Network: 20% maximum per visit. Point of Service: 30% maximum per visit
Specialist Office Visit
$35 maximum per visit. Point of Service: 30% maximum per visit
In Network: $35 maximum per visit. Point of Service: 30% maximum per visit

Prescription Drug Coverage

Drugs Covered under Medicare Part B

General

20% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs.


Drugs Covered under Medicare Part D

General

This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://www.mycignahealthspring.com on the web.

Different out-of-pocket costs may apply for people who
  • have limited incomes,
  • live in long term care facilities, or
  • have access to Indian/Tribal/Urban (Indian Health Service) providers.


The plan offers national in-network prescription coverage (i.e., this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel).

Total yearly drug costs are the total drug costs paid by both you and a Part D plan.

The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition.

Some drugs have quantity limits.

Your provider must get prior authorization from Cigna-HealthSpring Premier (HMO-POS) for certain drugs.

You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website, formulary, printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov.

If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will pay the actual cost, not the higher cost-sharing amount.

If you request a formulary exception for a drug and Cigna-HealthSpring Premier (HMO-POS) approves the exception, you will pay Tier 4: Non-Preferred Brand cost sharing for that drug.

In-Network

$0 deductible.

Initial Coverage

You pay the following until total yearly drug costs reach $2,850:

Retail Pharmacy

Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.

You can get drugs the following way(s):

Tier 1: Preferred Generic

  • $3 copay for a one-month (30-day) supply of drugs in this tier


  • $6 copay for a two-month (60-day) supply of drugs in this tier


  • $9 copay for a three-month (90-day) supply of drugs in this tier


  • Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.

    Tier 2: Non-Preferred Generic

  • $12 copay for a one-month (30-day) supply of drugs in this tier


  • $24 copay for a two-month (60-day) supply of drugs in this tier


  • $36 copay for a three-month (90-day) supply of drugs in this tier


  • Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.

    Tier 3: Preferred Brand

  • $45 copay for a one-month (30-day) supply of drugs in this tier


  • $90 copay for a two-month (60-day) supply of drugs in this tier


  • $135 copay for a three-month (90-day) supply of drugs in this tier


  • Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.

    Tier 4: Non-Preferred Brand

  • $85 copay for a one-month (30-day) supply of drugs in this tier


  • $170 copay for a two-month (60-day) supply of drugs in this tier


  • $255 copay for a three-month (90-day) supply of drugs in this tier


  • Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.

    Tier 5: Specialty Tier

  • 33% coinsurance for a one-month (30-day) supply of drugs in this tier


  • 33% coinsurance for a two-month (60-day) supply of drugs in this tier


  • 33% coinsurance for a three-month (90-day) supply of drugs in this tier


Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.

Long Term Care Pharmacy

Long term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time. They may also dispense less than a month's supply of generic drugs at a time. Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.

You can get drugs the following way(s):

Tier 1: Preferred Generic

  • $3 copay for a one-month (31-day) supply of drugs in this tier


  • Tier 2: Non-Preferred Generic

  • $12 copay for a one-month (31-day) supply of drugs in this tier


  • Tier 3: Preferred Brand

  • $45 copay for a one-month (31-day) supply of drugs in this tier


  • Tier 4: Non-Preferred Brand

  • $85 copay for a one-month (31-day) supply of drugs in this tier


  • Tier 5: Specialty Tier

  • 33% coinsurance for a one-month (31-day) supply of drugs in this tier



Mail Order


Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.

You can get drugs the following way(s):

Tier 1: Preferred Generic

  • $3 copay for a one-month (30-day) supply of drugs in this tier


  • $0 copay for a three-month (90-day) supply of drugs in this tier


  • Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.

    Tier 2: Non-Preferred Generic

  • $12 copay for a one-month (30-day) supply of drugs in this tier


  • $27 copay for a three-month (90-day) supply of drugs in this tier


  • Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.

    Tier 3: Preferred Brand

  • $45 copay for a one-month (30-day) supply of drugs in this tier


  • $125 copay for a three-month (90-day) supply of drugs in this tier


  • Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.

    Tier 4: Non-Preferred Brand

  • $85 copay for a one-month (30-day) supply of drugs in this tier


  • $245 copay for a three-month (90-day) supply of drugs in this tier


  • Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.

    Tier 5: Specialty Tier

  • 33% coinsurance for a one-month (30-day) supply of drugs in this tier


  • 33% coinsurance for a three-month (90-day) supply of drugs in this tier


Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.

Coverage Gap

After your total yearly drug costs reach $2,850, you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 47.5% for the plan's costs for brand drugs and 72% of the plan's costs for generic drugs until your yearly out-of-pocket drug costs reach $4,550.

Additional Coverage Gap

The plan covers many formulary generics (65%-99% of formulary generic drugs) through the coverage gap.

The plan offers additional coverage in the gap for the following tiers. You pay the following:

Retail Pharmacy

Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.

Tier 1: Preferred Generic

  • $3 copay for a one-month (30-day) supply of all drugs covered within this tier


  • $6 copay for a two-month (60-day) supply of all drugs covered within this tier


  • $9 copay for a three-month (90-day) supply of all drugs covered within this tier


  • Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.

    Tier 2: Non-Preferred Generic

  • $12 copay for a one-month (30-day) supply of all drugs covered within this tier


  • $24 copay for a two-month (60-day) supply of all drugs covered within this tier


  • $36 copay for a three-month (90-day) supply of all drugs covered within this tier


Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.

Long Term Care Pharmacy

Long term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time. They may also dispense less than a month's supply of generic drugs at a time. Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.

Tier 1: Preferred Generic

  • $3 copay for a one-month (31-day) supply of all drugs covered within this tier


  • Tier 2: Non-Preferred Generic

  • $12 copay for a one-month (31-day) supply of all drugs covered within this tier



Mail Order


Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.

Tier 1: Preferred Generic

  • $3 copay for a one-month (30-day) supply of all drugs covered within this tier


  • $0 copay for a three-month (90-day) supply of all drugs covered within this tier


  • Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.

    Tier 2: Non-Preferred Generic

  • $12 copay for a one-month (30-day) supply of all drugs covered within this tier


  • $27 copay for a three-month (90-day) supply of all drugs covered within this tier


Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.

Catastrophic Coverage

After your yearly out-of-pocket drug costs reach $4,550, you pay the greater of:
  • 5% coinsurance, or
  • $2.55 copay for generic (including brand drugs treated as generic) and a $6.35 copay for all other drugs.


Out-of-Network

Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Cigna-HealthSpring Premier (HMO-POS).

You can get out-of-network drugs the following way:

Out-of-Network Initial Coverage

You will be reimbursed up to the plan's cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2,850:

Out-of-Network Initial Coverage

Tier 1: Preferred Generic

  • $3 copay for a one-month (30-day) supply of drugs in this tier


  • Tier 2: Non-Preferred Generic

  • $12 copay for a one-month (30-day) supply of drugs in this tier


  • Tier 3: Preferred Brand

  • $45 copay for a one-month (30-day) supply of drugs in this tier


  • Tier 4: Non-Preferred Brand

  • $85 copay for a one-month (30-day) supply of drugs in this tier


  • Tier 5: Specialty Tier

  • 33% coinsurance for a one-month (30-day) supply of drugs in this tier


You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.

Out-of-Network Coverage Gap

You will be reimbursed up to 28% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4,550. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). You will be reimbursed up to 52.5% of the plan allowable cost for brand name drugs purchased out-of-network until your total yearly out-of-pocket drug costs reach $4,550. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s).

Additional Out-of-Network Coverage Gap

You will be reimbursed for these drugs purchased out-of-network up to the plan's cost of the drug minus the following:

Tier 1: Preferred Generic

  • $3 copay for a one-month (30-day) supply of all drugs covered within this tier


  • Tier 2: Non-Preferred Generic

  • $12 copay for a one-month (30-day) supply of all drugs covered within this tier


Out-of-Network Catastrophic Coverage

After your yearly out-of-pocket drug costs reach $4,550, you will be reimbursed for drugs purchased out-of-network up to the plan's cost of the drug minus your cost share, which is the greater of:
  • 5% coinsurance, or
  • $2.55 copay for generic (including brand drugs treated as generic) and a $6.35 copay for all other drugs.


You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.


Optional Supplemental Benefits

Optional Supplemental Package #1 Premium and Other Important Information Dental Services

Premium and Other Important Information

General

Package: 1 - Enhanced Dental - Comprehensive:

$25.30 monthly premium, in addition to your $0 monthly plan premium and the monthly Medicare Part B premium, for the following optional benefits:
  • Comprehensive Dental



Dental Services

General

Plan offers additional supplemental comprehensive dental benefits.

In-Network

$1,000 plan coverage limit for supplemental comprehensive dental benefits every year



General

Package: 1 - Enhanced Dental - Comprehensive:

$25.30 monthly premium, in addition to your $0 monthly plan premium and the monthly Medicare Part B premium, for the following optional benefits:
  • Comprehensive Dental




General

Plan offers additional supplemental comprehensive dental benefits.

In-Network

$1,000 plan coverage limit for supplemental comprehensive dental benefits every year


Premium and Other Important Information

General

Package: 1 - Enhanced Dental - Comprehensive:

$25.30 monthly premium, in addition to your $0 monthly plan premium and the monthly Medicare Part B premium, for the following optional benefits:
  • Comprehensive Dental



Dental Services

General

Plan offers additional supplemental comprehensive dental benefits.

In-Network

$1,000 plan coverage limit for supplemental comprehensive dental benefits every year


Other Services

Inpatient Care

Doctor and Hospital Choice



Referral required for network hospitals and specialists (for certain benefits).


,

Inpatient Hospital Care



Plan covers 90 days each benefit period.

For Medicare-covered hospital stays:

  • Days 1 - 6: $275 copay per day


  • Days 7 - 90: $0 copay per day


Plan covers 60 lifetime reserve days. $0 copay per lifetime reserve day.

Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital.


Outpatient Care

Inpatient Mental Health Care



You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital.

For Medicare-covered hospital stays:

  • Days 1 - 6: $245 copay per day


  • Days 7 - 90: $0 copay per day


Plan covers 60 lifetime reserve days. $0 copay per lifetime reserve day.

Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital.


,

Skilled Nursing Facility (SNF)



Authorization rules may apply.

Plan covers up to 100 days each benefit period

No prior hospital stay is required.

For SNF stays:

  • Days 1 - 5: $0 copay per day


  • Days 6 - 20: $25 copay per day


  • Days 21 - 100: $150 copay per day



,

Home Health Care



Authorization rules may apply.

$0 copay for Medicare-covered home health visits


,

Hospice



You must get care from a Medicare-certified hospice. You must consult with your plan before you select hospice.


,

Doctor Office Visits



Authorization rules may apply.

$10 copay for each Medicare-covered primary care doctor visit.

$35 copay for each Medicare-covered specialist visit.


Outpatient Medical Services and Supplies

Chiropractic Services



$20 copay for each Medicare-covered chiropractic visit

Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part).


,

Podiatry Services



$35 copay for each Medicare-covered podiatry visit

Medicare-covered podiatry visits are for medically necessary foot care.


,

Outpatient Mental Health Care



Authorization rules may apply.

$35 copay for each Medicare-covered individual therapy visit

$35 copay for each Medicare-covered group therapy visit

$35 copay for each Medicare-covered individual therapy visit with a psychiatrist

$35 copay for each Medicare-covered group therapy visit with a psychiatrist

$35 copay for Medicare-covered partial hospitalization program services


,

Outpatient Substance Abuse Care



Authorization rules may apply.

$35 copay for Medicare-covered individual substance abuse outpatient treatment visits

$35 copay for Medicare-covered group substance abuse outpatient treatment visits


,

Outpatient Services



Authorization rules may apply.

$300 copay for each Medicare-covered ambulatory surgical center visit

$300 copay for each Medicare-covered outpatient hospital facility visit


,

Ambulance Services



Authorization rules may apply.

20% of the cost for Medicare-covered ambulance benefits.

$150 copay for Medicare-covered ambulance benefits.


,

Emergency Care



$65 copay for Medicare-covered emergency room visits

$50,000 plan coverage limit for supplemental emergency services outside the U.S. and its territories every year.

If you are admitted to the hospital within 24-hour(s) for the same condition, you pay $0 for the emergency room visit.


,

Urgently Needed Care



$35 copay for Medicare-covered urgently-needed-care visits

If you are admitted to the hospital within 24-hour(s) for the same condition, you pay $0 for the urgently-needed-care visit.


,

Outpatient Rehabilitation Services



Authorization rules may apply.

Medically necessary physical therapy, occupational therapy, and speech and language pathology services are covered.

$25 copay for Medicare-covered Occupational Therapy visits

$25 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits


,

Durable Medical Equipment



Authorization rules may apply.

20% of the cost for Medicare-covered durable medical equipment


Preventive Services

Prosthetic Devices



Authorization rules may apply.

20% of the cost for Medicare-covered prosthetic devices

20% of the cost for Medicare-covered medical supplies related to prosthetics, splints, and other devices


,

Diabetes Programs and Supplies



Authorization rules may apply.

$0 copay for Medicare-covered Diabetes self-management training

0% to 20% of the cost for Medicare-covered Diabetes monitoring supplies

20% of the cost for Medicare-covered Therapeutic shoes or inserts

Diabetic Supplies and Services are limited to specific manufacturers, products and/or brands. Contact the plan for a list of covered supplies.


,

Diagnostic Tests, X-Rays, Lab Services, and Radiology Services



Authorization rules may apply.

$0 copay for Medicare-covered lab services

$0 to $200 copay for Medicare-covered diagnostic procedures and tests

$45 copay for Medicare-covered X-rays

$0 to $200 copay for Medicare-covered diagnostic radiology services (not including X-rays)

$60 copay for Medicare-covered therapeutic radiology services

If the doctor provides you services in addition to Outpatient Diagnostic Procedures, Tests and Lab Services, separate cost sharing of $10 to $35 may apply

If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services, separate cost sharing of $10 to $35 may apply


,

Cardiac and Pulmonary Rehabilitation Services



Authorization rules may apply.

$20 copay for Medicare-covered Cardiac Rehabilitation Services

$20 copay for Medicare-covered Intensive Cardiac Rehabilitation Services

$20 copay for Medicare-covered Pulmonary Rehabilitation Services


Additional Benefits

Preventive Services



$0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare.


,

Kidney Disease and Conditions



20% of the cost for Medicare-covered renal dialysis

$0 copay for Medicare-covered kidney disease education services


,

Dental Services



$0 copay for the following preventive dental benefits:

  • up to 1 oral exam(s) every six months


  • up to 1 cleaning(s) every six months


  • up to 1 dental x-ray(s) every year


$35 copay for Medicare-covered dental benefits


,

Hearing Services



In general, supplemental routine hearing exams and hearing aids not covered.

$10 to $35 copay for Medicare-covered diagnostic hearing exams


,

Vision Services



$0 to $35 copay for Medicare-covered exams to diagnose and treat diseases and conditions of the eye, including an annual glaucoma screening for people at risk

$0 copay for up to 1 supplemental routine eye exam(s) every year

$0 copay for
  • one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery


  • up to 1 pair(s) of eyeglasses (lenses and frames) every year


  • contact lenses


  • up to 1 pair(s) of eyeglass lenses every year


  • up to 1 eyeglass frame(s) every year


$200 plan coverage limit for supplemental eyewear every year

Plan offers additional vision benefits. Contact plan for details.


Cost Sharing Information

Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit

30 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$3 copay$3 copay$3 copay
Tier 2: Non-Preferred Generic$12 copay$12 copay$12 copay
Tier 3: Preferred Brand Name$45 copay$45 copay$45 copay
Tier 4: Non-Preferred Brand Name$85 copay$85 copay$85 copay
Tier 5: Specialty Tier33% coinsurance33% coinsurance33% coinsurance
90 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$9 copay$9 copay$0 copay
Tier 2: Non-Preferred Generic$36 copay$36 copay$27 copay
Tier 3: Preferred Brand Name$135 copay$135 copay$125 copay
Tier 4: Non-Preferred Brand Name$255 copay$255 copay$245 copay
Tier 5: Specialty Tier33% coinsurance33% coinsurance33% coinsurance

CMS Ratings

Staying healthy - screenings, tests and vaccines

Breast cancer screening
Not Rated
Colorectal cancer screening
Cholesterol screening for patients with heart disease
Glaucoma testing
Annual flu vaccine
Pneumonia vaccine
Improving or maintaining physical health
Improving or maintaining mental health
Monitoring physical ability
Access to primary care doctor visits
Adult BMI assessment

Managing Chronic Conditions

Care for older adults – medication review
Care for older adults – functional status assessment
Care for older adults – Pain screening
Osteoporosis management in women who had a fracture
Diabetes care – eye exam
Diabetes care – kidney disease monitoring
Diabetes care – blood sugar controlled
Diabetes care – cholesterol controlled
Controlling blood pressure
Rheumatoid arthritis management
Improving bladder control
Reducing the risk of falling
Plan all-cause readmissions

Ratings of Plan Responsiveness and Care

Getting needed care
Getting appointments and care quickly
Customer service
Overall rating of health care quality
Overall rating of plan

Member Complaints, Problems Getting Services, and Choosing to Leave the Plan

Complaints about the health plan
Beneficiary access and performance problems
Members choosing to leave the plan
Plan makes timely decision about appeals
Reviewing appeals decisions
Call center – foreign language interpreter and TTY/TDD availability

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Physicians that accept Cigna-HealthSpring Premier (HMO-POS) for Florida

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