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2015 Medicare Advantage Plan Benefit Details


Medicare Advantage Plan Benefit Details for:
Cigna-HealthSpring Preferred SMS (HMO)

2015 Medicare Advantage Plan Details
Plan Name:Cigna-HealthSpring Preferred SMS (HMO)
Location (County, State ZIP):George, Mississippi
Plan ID:H4407 - 002     Click to see other plans

Click here for the Cigna-HealthSpring Preferred SMS (HMO) enrollment options and to have a copy of this chart sent to your email. Enroll in Cigna-HealthSpring Preferred SMS (HMO)

— Plan Features —
Monthly Premium:$39.00 (See premium details below.)
Annual Rx Deductible:$0
Health Plan Type:Local HMO
Maximum Out-of-Pocket Limit
for Parts A & B (MOOP):
$5,900
Gap Coverage:Yes
Total Number of Formulary Drugs:3087    Browse Plan Formulary
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
  — Cost-Sharing during
       initial coverage phase:
$3.00$12.00$45.00$85.0033%
  — Number of Drugs per Tier:2881464482480373
Plan’s Summary Star Rating: 3.50 out of 5 Stars.
   - Customer Service Rating: Insufficient data to rate this plan.
   - Member Experience Rating: 4 out of 5 Stars.
   - Drug Cost Accuracy Rating: 3 out of 5 Stars.

— Plan Premium Details —
The Monthly Premium is Split as Follows:Total
Premium
Part C
Premium
Part D Base
Premium
Part D Supplemental
Premium
$39.00$6.80$32.20$0.00
Monthly Premium with Low-Income Subsidy:100%
Subsidy
75%
Subsidy
50%
Subsidy
25%
Subsidy
$2.90$10.20$17.50$24.90

— Plan Health Benefits —
** Cost **
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
$39 per month. In addition you must keep paying your Medicare Part B premium.
This plan does not have a deductible.
Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care.
Your yearly limit(s) in this plan:
  • $5 900 for services you receive from in-network providers.
If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.
Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.
Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply.
** Doctor and Hospital Choice **
Acupuncture and Other Alternative Therapies
Not covered
** Extra Benefits **
Inpatient Mental Health Care
For inpatient mental health care see the "Mental Health Care" section.
Outpatient Prescription Drugs
For Part B drugs such as chemotherapy drugs1:  20% of the cost
Other Part B drugs1:  20% of the cost
You pay the following until your total yearly drug costs reach $2 960. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.
You may get your drugs at network retail pharmacies and mail order pharmacies.
Standard Retail Cost-Sharing
TierOne-month supplyTwo-month supplyThree-month supply
Tier 1 (Preferred Generic)$3 copay$6 copay$9 copay
Tier 2 (Non-Preferred Generic)$12 copay$24 copay$36 copay
Tier 3 (Preferred Brand)$45 copay$90 copay$135 copay
Tier 4 (Non-Preferred Brand)$85 copay$170 copay$255 copay
Tier 5 (Specialty Tier)33% of the cost33% of the cost33% of the cost
Standard Mail Order Cost-Sharing
TierOne-month supplyThree-month supply
Tier 1 (Preferred Generic)$3 copay$9 copay
Tier 2 (Non-Preferred Generic)$12 copay$36 copay
Tier 3 (Preferred Brand)$45 copay$135 copay
Tier 4 (Non-Preferred Brand)$85 copay$255 copay
Tier 5 (Specialty Tier)33% of the cost33% of the cost
If you reside in a long-term care facility you pay the same as at a retail pharmacy.
You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network pharmacy.
Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $2 960.

After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 65% of the plan's cost for covered generic drugs until your costs total $4 700 which is the end of the coverage gap. Not everyone will enter the coverage gap.

Under this plan you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you.
Standard Retail Cost-Sharing
TierDrugs CoveredOne-month supplyTwo-month supplyThree-month supply
Tier 1 (Preferred Generic)All$3 copay$6 copay$9 copay
Tier 2 (Non-Preferred Generic)All$12 copay$24 copay$36 copay
Standard Mail Order Cost-Sharing
TierDrugs CoveredOne-month supplyThree-month supply
Tier 1 (Preferred Generic)All$3 copay$9 copay
Tier 2 (Non-Preferred Generic)All$12 copay$36 copay
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 700 you pay the greater of:
  • 5% of the cost or
  • $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copayment for all other drugs.
** Important Information **
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
$39 per month. In addition you must keep paying your Medicare Part B premium.
This plan does not have a deductible.
Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care.
Your yearly limit(s) in this plan:
  • $5 900 for services you receive from in-network providers.
If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.
Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.
Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply.
** Outpatient Care and Services **
Acupuncture and Other Alternative Therapies
Not covered
Ambulance Services
$150 copay or 20% of the cost depending on the service
Chiropractic Care
Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position):  $20 copay
Dental Services
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth):  $40 copay
Preventive dental services:
  • Cleaning (for up to 1 every six months):  You pay nothing
  • Dental x-ray(s) (for up to 1 every year):  You pay nothing
  • Oral exam (for up to 1 every six months):  You pay nothing
  • Diabetes Supplies and Services
    Diabetes monitoring supplies:  0-20% of the cost depending on the supply
    Diabetes self-management training:  You pay nothing
    Therapeutic shoes or inserts:  20% of the cost
    Diagnostic Tests, Lab and Radiology Services, and X-Rays
    Diagnostic radiology services (such as MRIs CT scans):  $0-200 copay depending on the service
    Diagnostic tests and procedures:  $0-200 copay depending on the service
    Lab services:  You pay nothing
    Outpatient x-rays:  $30 copay
    Therapeutic radiology services (such as radiation treatment for cancer):  $60 copay
    Doctor’s Office Visits
    Primary care physician visit:  $10 copay
    Specialist visit:  $40 copay
    Durable Medical Equipment (wheelchairs, oxygen, etc.)
    20% of the cost
    Emergency Care
    $65 copay
    If you are admitted to the hospital within 24 hours you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section for other costs.
    Foot Care (podiatry services)
    Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:  $40 copay
    Hearing Services
    Exam to diagnose and treat hearing and balance issues:  $10-40 copay depending on the service
    Home Health Care
    You pay nothing
    Mental Health Care
    Inpatient visit:
    Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital.
    Our plan covers 90 days for an inpatient hospital stay.
    Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days you can use these extra days. But once you have used up these extra 60 days your inpatient hospital coverage will be limited to 90 days.
    • $245 copay per day for days 1 through 6
    • You pay nothing per day for days 7 through 90
    • Outpatient group therapy visit:  $40 copay
      Outpatient individual therapy visit:  $40 copay
      Outpatient Rehabilitation Services
      Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks):  $20 copay
      Occupational therapy visit:  $25 copay
      Physical therapy and speech and language therapy visit:  $25 copay
      Outpatient Substance Abuse
      Group therapy visit:  $40 copay
      Individual therapy visit:  $40 copay
      Outpatient Surgery
      Ambulatory surgical center:  $150 copay
      Outpatient hospital:  $225 copay
      Over-the-Counter Items
      Not Covered
      Prosthetic Devices (braces, artificial limbs, etc.)
      Prosthetic devices:  20% of the cost
      Related medical supplies:  20% of the cost
      Renal Dialysis
      20% of the cost
      Transportation
      Not covered
      Urgently Needed Care
      $40 copay
      If you are admitted to the hospital within 24 hours you do not have to pay your share of the cost for urgent care. See the "Inpatient Hospital Care" section for other costs.
      Vision Services
      Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):  $0-40 copay depending on the service
      Routine eye exam (for up to 1 every year):  You pay nothing
      Contact lenses:  You pay nothing
      Eyeglasses (frames and lenses) (for up to 1 every year):  You pay nothing
      Eyeglass frames (for up to 1 every year):  You pay nothing
      Eyeglass lenses (for up to 1 every year):  You pay nothing
      Eyeglasses or contact lenses after cataract surgery:  You pay nothing
      Our plan pays up to $100 every year for eyewear.
      ** Hospice **
      Hospice
      You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care.
      ** Preventive Care **
      Preventive Care
      You pay nothing
      Our plan covers many preventive services including:
      • Abdominal aortic aneurysm screening
      • Alcohol misuse counseling
      • Bone mass measurement
      • Breast cancer screening (mammogram)
      • Cardiovascular disease (behavioral therapy)
      • Cardiovascular screenings
      • Cervical and vaginal cancer screening
      • Colonoscopy
      • Colorectal cancer screenings
      • Depression screening
      • Diabetes screenings
      • Fecal occult blood test
      • Flexible sigmoidoscopy
      • HIV screening
      • Medical nutrition therapy services
      • Obesity screening and counseling
      • Prostate cancer screenings (PSA)
      • Sexually transmitted infections screening and counseling
      • Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
      • Vaccines including Flu shots Hepatitis B shots Pneumococcal shots
      • "Welcome to Medicare" preventive visit (one-time)
      • Yearly "Wellness" visit
      Any additional preventive services approved by Medicare during the contract year will be covered.
      ** Inpatient Care **
      Inpatient Hospital Care
      Our plan covers 90 days for an inpatient hospital stay.
      Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days you can use these extra days. But once you have used up these extra 60 days your inpatient hospital coverage will be limited to 90 days.
      • $260 copay per day for days 1 through 6
      • You pay nothing per day for days 7 through 90
      • Inpatient Mental Health Care
        For inpatient mental health care see the "Mental Health Care" section.
        Skilled Nursing Facility (SNF)
        Our plan covers up to 100 days in a SNF.
          • $0 copay per day for days 1 through 20
          • $150 copay per day for days 21 through 100
          Outpatient Prescription Drugs
          For Part B drugs such as chemotherapy drugs1:  20% of the cost
          Other Part B drugs1:  20% of the cost
          You pay the following until your total yearly drug costs reach $2 960. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.
          You may get your drugs at network retail pharmacies and mail order pharmacies.
          Standard Retail Cost-Sharing
          TierOne-month supplyTwo-month supplyThree-month supply
          Tier 1 (Preferred Generic)$3 copay$6 copay$9 copay
          Tier 2 (Non-Preferred Generic)$12 copay$24 copay$36 copay
          Tier 3 (Preferred Brand)$45 copay$90 copay$135 copay
          Tier 4 (Non-Preferred Brand)$85 copay$170 copay$255 copay
          Tier 5 (Specialty Tier)33% of the cost33% of the cost33% of the cost
          Standard Mail Order Cost-Sharing
          TierOne-month supplyThree-month supply
          Tier 1 (Preferred Generic)$3 copay$9 copay
          Tier 2 (Non-Preferred Generic)$12 copay$36 copay
          Tier 3 (Preferred Brand)$45 copay$135 copay
          Tier 4 (Non-Preferred Brand)$85 copay$255 copay
          Tier 5 (Specialty Tier)33% of the cost33% of the cost
          If you reside in a long-term care facility you pay the same as at a retail pharmacy.
          You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network pharmacy.
          Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $2 960.

          After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 65% of the plan's cost for covered generic drugs until your costs total $4 700 which is the end of the coverage gap. Not everyone will enter the coverage gap.

          Under this plan you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you.
          Standard Retail Cost-Sharing
          TierDrugs CoveredOne-month supplyTwo-month supplyThree-month supply
          Tier 1 (Preferred Generic)All$3 copay$6 copay$9 copay
          Tier 2 (Non-Preferred Generic)All$12 copay$24 copay$36 copay
          Standard Mail Order Cost-Sharing
          TierDrugs CoveredOne-month supplyThree-month supply
          Tier 1 (Preferred Generic)All$3 copay$9 copay
          Tier 2 (Non-Preferred Generic)All$12 copay$36 copay
          After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 700 you pay the greater of:
          • 5% of the cost or
          • $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copayment for all other drugs.
          ** Outpatient Care **
          Diabetes Supplies and Services
          Diabetes monitoring supplies:  0-20% of the cost depending on the supply
          Diabetes self-management training:  You pay nothing
          Therapeutic shoes or inserts:  20% of the cost
          Foot Care (podiatry services)
          Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:  $40 copay
          Hearing Services
          Exam to diagnose and treat hearing and balance issues:  $10-40 copay depending on the service
          ** Outpatient Medical Services and Supplies **
          Outpatient Substance Abuse
          Group therapy visit:  $40 copay
          Individual therapy visit:  $40 copay
          Prosthetic Devices (braces, artificial limbs, etc.)
          Prosthetic devices:  20% of the cost
          Related medical supplies:  20% of the cost
          ** Additional Benefits **
          Inpatient Mental Health Care
          For inpatient mental health care see the "Mental Health Care" section.
          ** Cost **
          Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
          Package 1: Enhanced Dental - Comprehensive
          Benefits include:
          • Comprehensive Dental
          Additional $14.10 per month. You must keep paying your Medicare Part B premium and your $39 monthly plan premium.
          This package does not have a deductible.
          Our plan pays up to $1000 every year.
          ** Important Information **
          Package 1: Enhanced Dental - Comprehensive
          Benefits include:
          • Comprehensive Dental
          Additional $14.10 per month. You must keep paying your Medicare Part B premium and your $39 monthly plan premium.
          This package does not have a deductible.
          Our plan pays up to $1000 every year.

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