Plan Basics
Contract Year |
2021 |
Medicare Type |
Medicare Advantage Plan (Part C) |
CMS Plan ID |
H0439-003-001 |
Plan Organization |
Cigna |
Plan Type |
Local HMO |
Plan Name |
Cigna Preferred GA Medicare (HMO) |
Plan Organization Type |
Local CCP |
Drugs Covered |
Yes |
Doctors Choice |
Plan Doctors for Most Services |
Benefit Type |
Enhanced Alternative |
Special Needs Plan |
No |
Overall Star Rating |
3.5 |
Plan Cost Sharing
Premium |
$0.00 |
Total Premium (Includes Part B) |
$135.50 |
Monthly Part C Premium |
$0.00 |
Monthly Part D Basic Premium |
$0.00 |
Monthly Part D Supplemental Premium |
$0.00 |
Monthly Part D Total Premium |
$0.00 |
Monthly Part D Premium Full Assistance |
$0.00 |
Monthly Part D Premium 75% Assistance |
$0.00 |
Monthly Part D Premium 50% Assistance |
$0.00 |
Monthly Part D Premium 25% Assistance |
$0.00 |
Part D Drug Deductible |
$300.00 |
Annual Drug Deductible |
$300.00 |
Tiers Excluded From Deductible |
1 |
Part D Initial Coverage Limit |
$4130.00 |
Part D Catastrophic Coverage Threshold |
$6550.00 |
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) |
$7500.00 |
Gap Coverage |
No |
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 |
- |
- |
Yes, contact plan for further details |
Comprehensive Dental
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Diagnostic services |
Yes |
- |
Yes |
No |
$0 copay |
Endodontics |
Yes |
- |
Yes |
No |
$0 copay |
Extractions |
Yes |
- |
Yes |
No |
$0 copay |
Non-routine services |
Yes |
- |
Yes |
No |
$0 copay |
Periodontics |
Yes |
- |
Yes |
No |
$0 copay |
Prosthodontics, other oral/maxillofacial surgery, other services |
Yes |
- |
Yes |
No |
$0 copay |
Restorative services |
Yes |
- |
Yes |
No |
$0 copay |
Diagnostic Procedures/lab Services/imaging
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Diagnostic radiology services (e.g., MRI) |
- |
- |
Yes |
No |
$0-225 copay |
Diagnostic tests and procedures |
- |
- |
Yes |
No |
$0-225 copay |
Lab services |
- |
- |
Yes |
No |
$0 copay |
Outpatient x-rays |
- |
- |
Yes |
No |
$0-25 copay |
Doctor Visits
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Primary |
- |
- |
- |
- |
$5 copay per visit |
Specialist |
- |
- |
Yes |
No |
$40 copay per visit |
Emergency Care/Urgent Care
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Emergency |
- |
- |
- |
- |
$90 copay per visit (always covered) |
Urgent care |
- |
- |
- |
- |
$50 copay per visit (always covered) |
Foot Care (podiatry Services)
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Foot exams and treatment |
- |
- |
No |
No |
$40 copay |
Routine foot care |
- |
- |
- |
- |
Not covered |
Ground Ambulance
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
- |
- |
- |
$260 copay |
Health Plan Deductible
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
- |
- |
- |
$0 |
Hearing
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Fitting/evaluation |
Yes |
- |
No |
No |
$0 copay |
Hearing aids - inner ear |
Yes |
- |
No |
No |
$0 copay |
Hearing aids - outer ear |
Yes |
- |
No |
No |
$0 copay |
Hearing aids - over the ear |
Yes |
- |
No |
No |
$0 copay |
Hearing exam |
- |
- |
No |
No |
$5-40 copay |
Inpatient Hospital Coverage
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
- |
Yes |
No |
$330 per day for days 1 through 6$0 per day for days 7 through 90 |
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
- |
- |
- |
$7,500 In-network |
Medical Equipment/supplies
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Diabetes supplies |
- |
- |
Yes |
- |
0-20% coinsurance per item |
Durable medical equipment (e.g., wheelchairs, oxygen) |
- |
- |
Yes |
- |
20% coinsurance per item |
Prosthetics (e.g., braces, artificial limbs) |
- |
- |
Yes |
- |
20% coinsurance per item |
Medicare Part B Drugs
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Chemotherapy |
- |
- |
Yes |
- |
20% coinsurance |
Other Part B drugs |
- |
- |
Yes |
- |
20% coinsurance |
Mental Health Services
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Inpatient hospital - psychiatric |
- |
- |
Yes |
No |
$595 per day for days 1 through 3$0 per day for days 4 through 90 |
Outpatient group therapy visit |
- |
- |
Yes |
No |
$0 copay |
Outpatient group therapy visit with a psychiatrist |
- |
- |
Yes |
No |
$0 copay |
Outpatient individual therapy visit |
- |
- |
Yes |
No |
$0 copay |
Outpatient individual therapy visit with a psychiatrist |
- |
- |
Yes |
No |
$0 copay |
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 |
Outpatient Hospital Coverage
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
- |
Yes |
No |
$0-325 copay per visit |
Preventive Care
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
- |
No |
No |
$0 copay |
Preventive Dental
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Cleaning |
Yes |
- |
No |
No |
$0 copay |
Dental x-ray(s) |
Yes |
- |
No |
No |
$0 copay |
Fluoride treatment |
Yes |
- |
No |
No |
$0 copay |
Oral exam |
Yes |
- |
No |
No |
$0 copay |
Rehabilitation Services
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Occupational therapy visit |
- |
- |
Yes |
No |
$40 copay |
Physical therapy and speech and language therapy visit |
- |
- |
Yes |
No |
$40 copay |
Skilled Nursing Facility
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
- |
Yes |
No |
$0 per day for days 1 through 20$184 per day for days 21 through 100 |
Transportation
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
- |
- |
- |
Not covered |
Vision
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Contact lenses |
Yes |
- |
No |
No |
$0 copay |
Eyeglass frames |
Yes |
- |
No |
No |
$0 copay |
Eyeglass lenses |
Yes |
- |
No |
No |
$0 copay |
Eyeglasses (frames and lenses) |
Yes |
- |
No |
No |
$0 copay |
Other |
No |
- |
- |
- |
Not covered |
Routine eye exam |
Yes |
- |
No |
No |
$0 copay |
Upgrades |
Yes |
- |
No |
No |
$0 copay |
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
- |
No |
No |
Covered |
Official Medicare Contact
Medicare Phone |
1-800-MEDICARE (1-800-633-4227) |
Medicare TTY User |
1-877-486-2048 |
Plan Available in these Counties
Barrow County, Georgia,
Butts County, Georgia,
Clarke County, Georgia,
Clayton County, Georgia,
Dekalb County, Georgia,
Douglas County, Georgia,
Franklin County, Georgia,
Fulton County, Georgia,
Greene County, Georgia,
Gwinnett County, Georgia,
Henry County, Georgia,
Madison County, Georgia,
Morgan County, Georgia,
Newton County, Georgia,
Oconee County, Georgia,
Oglethorpe County, Georgia,
Rockdale County, Georgia,
Spalding County, Georgia,
Walton County, Georgia
NOTE: Information on MedicarePolicyHelper.com is for educational purposes only. We are not affiliated with Medicare, or CMS. Medicare has not reviewed or endorsed the information on our site. All plan data on our site comes directly from medicare.gov and is subject to change.