Cigna TotalCare (HMO D-SNP) H4513-034-000 is a 2021 Medicare Advantage Dual-Eligible Special Needs Plan provided by Cigna.

A Special Needs Plan (SNP) is a type of Medicare Advantage Plan designed for Medicare beneficiaries with specific conditions or characteristics.

Dual Eligible Special Needs Plans are for beneficiaries enrolled in Medicare and Medicaid. This includes all categories of Medicaid. Please only choose this plan if you are eligible for both Medicare and Medicaid.

Special Needs plans provide both health coverage and drug coverage, and each coverage type has different costs to consider.

This plan has a monthly premium of $25.50, which covers both the health and drug portions of the plan.

When it comes to out-of-pocket costs for drugs, this plan has a Part D drug Deductible of $445.00 and an Initial Coverage Limit of $4130. Each drug tier may be subject to different cost-sharing in each coverage phase, so keep that in mind when considering out-of-pocket costs. Check out the drug formulary below for more information, or reach out to a licensed Medicare agent for help using the call number on this page. Alternatively, if you know what plan you want, you can enroll online yourself using our site as well.


Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H4513-034-000
Plan Organization Cigna
Plan Type Local HMO
Plan Name Cigna TotalCare (HMO D-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 Dual-Eligible
Overall Star Rating 4.5
Plan Cost Sharing
Premium $25.50
Total Premium (Includes Part B) $161.00
Monthly Part C Premium $0.00
Monthly Part D Basic Premium $25.50
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $25.50
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $6.40
Monthly Part D Premium 50% Assistance $12.70
Monthly Part D Premium 25% Assistance $19.10
Part D Drug Deductible $445.00
Annual Drug Deductible $445.00
Part D Initial Coverage Limit $4130.00
Part D Catastrophic Coverage Threshold $6550.00

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 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% or 0-20% coinsurance
Diagnostic tests and procedures - - Yes No 0% or 0-20% coinsurance
Lab services - - Yes No $0 copay
Outpatient x-rays - - Yes No $0 copay
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - - - - $0 copay
Specialist - - Yes No $0 copay
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $0 or $90 copay per visit (always covered)
Urgent care - - - - $0 copay
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - - No No $0 copay
Routine foot care - - - - Not covered
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - 0% or 20% coinsurance
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 $0 copay
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No $0 or $195 per day for days 1 through 10$0 per day for days 11 through 90
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $6,700 In-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - - Yes - 0% or 0-20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen) - - Yes - 0% or 20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) - - Yes - 0% or 20% coinsurance per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - - Yes - 0% or 20% coinsurance
Other Part B drugs - - Yes - 0% or 20% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - - Yes No $0 or $176 per day for days 1 through 10$0 per day for days 11 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% or 0-20% coinsurance 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 $0 copay
Physical therapy and speech and language therapy visit - - Yes No $0 copay
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No $0 per day for days 1 through 20$0 or $184 per day for days 21 through 100
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
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
Plan Drug Info
Formulary Link Drug Formulary Directory
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048
Plan Available in these Counties
Bedford County, Tennessee, Benton County, Tennessee, Cannon County, Tennessee, Carroll County, Tennessee, Cheatham County, Tennessee, Chester County, Tennessee, Clay County, Tennessee, Coffee County, Tennessee, Crockett County, Tennessee, Cumberland County, Tennessee, Davidson County, Tennessee, Decatur County, Tennessee, Dekalb County, Tennessee, Dickson County, Tennessee, Fayette County, Tennessee, Fentress County, Tennessee, Gibson County, Tennessee, Giles County, Tennessee, Hardeman County, Tennessee, Hardin County, Tennessee, Haywood County, Tennessee, Henderson County, Tennessee, Hickman County, Tennessee, Houston County, Tennessee, Humphreys County, Tennessee, Jackson County, Tennessee, Lauderdale County, Tennessee, Lawrence County, Tennessee, Lewis County, Tennessee, Lincoln County, Tennessee, Macon County, Tennessee, Madison County, Tennessee, Marshall County, Tennessee, Maury County, Tennessee, Mcnairy County, Tennessee, Montgomery County, Tennessee, Moore County, Tennessee, Overton County, Tennessee, Perry County, Tennessee, Pickett County, Tennessee, Putnam County, Tennessee, Robertson County, Tennessee, Rutherford County, Tennessee, Shelby County, Tennessee, Smith County, Tennessee, Stewart County, Tennessee, Sumner County, Tennessee, Tipton County, Tennessee, Trousdale County, Tennessee, Van Buren County, Tennessee, Warren County, Tennessee, Wayne County, Tennessee, White County, Tennessee, Williamson County, Tennessee, Wilson County, Tennessee

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.