Plan Basics
Contract Year 2020
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H2108-029-000
Plan Organization Cigna
Plan Type Local HMO
Plan Name Cigna-HealthSpring Achieve (HMO C-SNP)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Plan Doctors for Most Services
Benefit Type Enhanced Alternative
Special Needs Plan Yes
Special Needs Plan Type Chronic or Disabling Condition
Conditions Covered Diabetes Mellitus
Overall Star Rating 3.5 Stars
Plan Cost Sharing
Premium $68.00
Total Premium (Includes Part B) $203.50
Monthly Part C Premium $65.70
Monthly Part D Basic Premium $2.30
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $2.30
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $0.60
Monthly Part D Premium 50% Assistance $1.10
Monthly Part D Premium 25% Assistance $1.70
Part D Drug Deductible $280.00
Annual Drug Deductible $280.00
Tiers Excluded From Deductible 1
Part D Initial Coverage Limit $4020.00
Part D Catastrophic Coverage Threshold $6350.00
Formulary Website Formulary Link

Medicare Advantage Plan Health Benefits


Additional Benefits And/or Reduced Cost-sharing For Enrollees With Certain Health Conditions?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic services No - - - Not covered
Restorative services No - - - Not covered
Non-routine services No - - - Not covered
Periodontics No - - - Not covered
Prosthodontics, other oral/maxillofacial surgery, other services No - - - Not covered
Endodontics No - - - Not covered
Extractions No - - - Not covered
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic tests and procedures - - Yes No $0-50
Outpatient x-rays - - Yes No $20
Diagnostic radiology services (e.g., MRI) - - Yes No $0-225
Lab services - - Yes No $0 copay
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - - No No $40
Routine foot care - - - - Not covered
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Fitting/evaluation Yes - No No $0 copay
Hearing exam - - No No $0-40
Hearing aids - over the ear Yes - No No $0 copay
Hearing aids - inner ear No - - - Not covered
Hearing aids - outer ear Yes - No No $0 copay
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - - No - $0 copay
Durable medical equipment (e.g., wheelchairs, oxygen) - - Yes - 20% per item
Prosthetics (e.g., braces, artificial limbs) - - Yes - 20% per item
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Outpatient group therapy visit - - Yes No $40
Outpatient individual therapy visit with a psychiatrist - - Yes No $40
Outpatient group therapy visit with a psychiatrist - - Yes No $40
Inpatient hospital - psychiatric - - Yes No $350 per day for days 1 through 5 $0 per day for days 6 through 90
Outpatient individual therapy visit - - Yes No $40
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Yes
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Oral exam Yes - Yes No $0 copay
Cleaning Yes - Yes No $0 copay
Dental x-ray(s) Yes - Yes No $0 copay
Fluoride treatment No - - - Not covered
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
Yes - Yes No $0 copay
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Routine eye exam Yes - Yes No $0 copay
Contact lenses Yes - No No $0 copay
Eyeglass frames Yes - No No $0 copay
Other No - - - Not covered
Eyeglass lenses Yes - No No $0 copay
Upgrades Yes - No No $0 copay
Eyeglasses (frames and lenses) Yes - No No $0 copay
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - - - - $0 copay
Specialist - - No No $40 per visit
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $90 per visit (always covered)
Urgent care - - - - $55 per visit (always covered)
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $220
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Physical therapy and speech and language therapy visit - - Yes No $40
Occupational therapy visit - - Yes No $40
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $3,400 In-network
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - - Yes - 20%
Other Part B drugs - - Yes - 20%
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No $0-300 per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No $0 copay
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No Covered
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $199 In-network
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No $300 per day for days 1 through 6 $0 per day for days 7 through 90
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No $0 per day for days 1 through 20 $178 per day for days 21 through 100

Medicare Plan Packages


Package #1
Category Cost Sharing Type Cost Share
Comprehensive dental Monthly Premium
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048

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