Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H7849-013-000
Plan Organization Cigna
Plan Type Local PPO
Plan Name Cigna True Choice Medicare (PPO)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Any Doctor
Benefit Type Enhanced Alternative
Special Needs Plan No
Overall Star Rating Plan too new to be measured
Plan Cost Sharing
Premium $0.00
Total Premium (Includes Part B) $115.50
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 $0.00
Part D Initial Coverage Limit $4130.00
Part D Catastrophic Coverage Threshold $6550.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $5100.00
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 Out-of-Network Yes No $0 copay
Endodontics Yes Out-of-Network Yes No $0 copay
Extractions Yes Out-of-Network Yes No $0 copay
Non-routine services Yes Out-of-Network Yes No $0 copay
Periodontics Yes Out-of-Network Yes No $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services Yes Out-of-Network Yes No $0 copay
Restorative services Yes Out-of-Network Yes No $0 copay
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - Out-of-Network Yes No 35% coinsurance
Diagnostic tests and procedures - Out-of-Network Yes No 35% coinsurance
Lab services - Out-of-Network Yes No 0-35% coinsurance
Outpatient x-rays - Out-of-Network Yes No 35% coinsurance
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - Out-of-Network - - $40 copay per visit
Specialist - Out-of-Network Yes No $55 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 - - - - $25 copay per visit (always covered)
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - Out-of-Network No No $55 copay
Routine foot care - - - - Not covered
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - $210 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 Out-of-Network No No 35% coinsurance
Hearing aids - inner ear Yes Out-of-Network No No $0 copay
Hearing aids - outer ear Yes Out-of-Network No No $0 copay
Hearing aids - over the ear Yes Out-of-Network No No $0 copay
Hearing exam - Out-of-Network No No $55 copay
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No 35% per stay
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $7,700 In and Out-of-network$5,100 In-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - Out-of-Network Yes - 35% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen) - Out-of-Network Yes - 35% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) - Out-of-Network Yes - 35% coinsurance per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - Out-of-Network Yes - 35% coinsurance
Other Part B drugs - Out-of-Network Yes - 35% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - Out-of-Network Yes No 35% per stay
Outpatient group therapy visit - Out-of-Network Yes No $55 copay
Outpatient group therapy visit with a psychiatrist - Out-of-Network Yes No $55 copay
Outpatient individual therapy visit - Out-of-Network Yes No $55 copay
Outpatient individual therapy visit with a psychiatrist - Out-of-Network Yes No $55 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
- Out-of-Network Yes No 35% coinsurance per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network No No $0 copay
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning Yes Out-of-Network No No $0 copay
Dental x-ray(s) Yes Out-of-Network No No $0 copay
Fluoride treatment Yes Out-of-Network No No $0 copay
Oral exam Yes Out-of-Network No No $0 copay
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - Out-of-Network Yes No $55 copay
Physical therapy and speech and language therapy visit - Out-of-Network Yes No $55 copay
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No 35% per stay
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 Out-of-Network No No $0 copay
Eyeglass frames Yes Out-of-Network No No $0 copay
Eyeglass lenses Yes Out-of-Network No No $0 copay
Eyeglasses (frames and lenses) Yes Out-of-Network No No $0 copay
Other No - - - Not covered
Routine eye exam Yes Out-of-Network No No 35% coinsurance
Upgrades Yes Out-of-Network 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

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