Plan Basics
Contract Year 2020
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H2108-020-000
Plan Organization Cigna
Plan Type Local HMO
Plan Name Cigna-HealthSpring Traditions (HMO I-SNP)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Plan Doctors for Most Services
Benefit Type Defined Standard Benefit
Special Needs Plan Yes
Special Needs Plan Type Institutional
Overall Star Rating 3.5 Stars
Plan Cost Sharing
Premium $29.60
Total Premium (Includes Part B) $165.10
Monthly Part D Basic Premium $29.60
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $29.60
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $7.40
Monthly Part D Premium 50% Assistance $14.80
Monthly Part D Premium 25% Assistance $22.20
Part D Drug Deductible $435.00
Annual Drug Deductible $435.00
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
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Outpatient x-rays - - Yes No 20%
Diagnostic radiology services (e.g., MRI) - - Yes No 0-20%
Lab services - - Yes No $0 copay
Diagnostic tests and procedures - - Yes No 0-20%
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Specialist - - No No 20% per visit
Primary - - - - $0 copay
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Hearing aids - outer ear Yes - No No $0 copay
Hearing aids - over the ear Yes - No No $0 copay
Hearing aids - inner ear No - - - Not covered
Fitting/evaluation Yes - No No $0 copay
Hearing exam - - No No 0-20%
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No $390 per day for days 1 through 5 $0 per day for days 6 through 90
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Prosthetics (e.g., braces, artificial limbs) - - Yes - 20% per item
Diabetes supplies - - No - 0-20% per item
Durable medical equipment (e.g., wheelchairs, oxygen) - - Yes - 20% per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - - Yes - 20%
Other Part B drugs - - Yes - 20%
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Outpatient group therapy visit - - Yes No 20%
Outpatient group therapy visit with a psychiatrist - - Yes No 20%
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 with a psychiatrist - - Yes No 20%
Outpatient individual therapy visit - - Yes No 20%
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No 0-20% per visit
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Dental x-ray(s) Yes - Yes No $0 copay
Fluoride treatment No - - - Not covered
Cleaning Yes - Yes No $0 copay
Oral exam Yes - Yes No $0 copay
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - - Yes No 10%
Physical therapy and speech and language therapy visit - - Yes No 10%
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
Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Periodontics Yes - Yes No $0 copay
Restorative services Yes - Yes No $0 copay
Endodontics Yes - Yes No $0 copay
Non-routine services No - - - Not covered
Diagnostic services No - - - Not covered
Extractions Yes - Yes No $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services Yes - Yes No $0 copay
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Urgent care - - - - 20% per visit (always covered)
Emergency - - - - $90 per visit (always covered)
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - 20%
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - No
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No $0 copay
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses Yes - No No $0 copay
Eyeglass lenses Yes - No No $0 copay
Upgrades Yes - No No $0 copay
Eyeglass frames Yes - No No $0 copay
Other No - - - Not covered
Routine eye exam Yes - Yes No $0 copay
Eyeglasses (frames and lenses) Yes - No No $0 copay
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - - No No 20%
Routine foot care Yes - No No $0 copay
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $6,700 In-network
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
- - - - $0
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
Yes - Yes No $0 copay
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048

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