SUMMARY OF BENEFITS - Cigna · This Summary of Benefits booklet ... as listed in the OTC catalog....

SUMMARY OF BENEFITS January 1 2016 - December 31 2016

Cigna-HealthSpringreg TotalCare (HMO SNP) H4513 - 010

copy 2015 Cigna H4513_16_32742 Accepted

SECTION I - INTRODUCTION TO SUMMARY OF BENEFITS

This booklet gives you a summary of what we cover and what you pay It doesnrsquot list every service that we cover or list every limitation or exclusion To get a complete list of services we cover call us and ask for the ldquoEvidence of Coveragerdquo

You have choices about how to get your Medicare benefits

bull One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare) Original Medicare is run directly by the Federal government

bull Another choice is to get your Medicare benefits by joining a Medicare health plan (such as Cigna-HealthSpring TotalCare (HMO SNP))

Tips for comparing your Medicare choices

This Summary of Benefits booklet gives you a summary of what Cigna-HealthSpring TotalCare (HMO SNP) covers and what you pay

bull If you want to compare our plan with other Medicare health plans ask the other plans for their Summary of Benefits booklets Or use the Medicare Plan Finder on httpwwwmedicaregov

Sections in this booklet

bull Things to Know About Cigna-HealthSpring TotalCare (HMO SNP)

bull Monthly Premium Deductible and Limits on How Much You Pay for Covered Services

bull Covered Medical and Hospital Benefits

bull Prescription Drug Benefits

bull If you want to know more about the coverage and costs of Original Medicare look in your current ldquoMedicare amp Yourdquo handbook View it online at httpwwwmedicaregov or get a copy by calling 1-800-MEDICARE (1-800-633-4227) 24 hours a day 7 days a week TTY users should call 1-877-486-2048

This document is available in other formats such as Braille and large print

This document may be available in a non-English language For additional information call us at 1-800-668-3813

Este documento puede estar disponible en un idioma distinto al ingleacutes Para obtener informacioacuten adicional llaacutemenos al 1-800-668-3813

THINGS TO KNOW ABOUT CIGNA-HEALTHSPRING TOTALCARE (HMO SNP)

Hours of Operation Which doctors hospitals and pharmacies can I use

You can call us 7 days a week from 800 am to 800 pm Local time Cigna-HealthSpring TotalCare

(HMO SNP) has a network of doctors Cigna-HealthSpring TotalCare hospitals pharmacies and other (HMO SNP) Phone Numbers providers If you use the providers that and Website are not in our network the plan may not

pay for these services bull If you are a member of this plan

call toll-free 1-800-668-3813 You must generally use network pharmacies to fill your prescriptions

bull If you are not a member of this plan for covered Part D

call toll-free 1-800-846-2098 You can see our plans provider directory

bull Our website at our website

httpwwwcignahealthspringcom (wwwcignahealthspringcom) You can see our plans pharmacy directory at our

Who can join website (wwwcignahealthspringcom)

To join Cigna-HealthSpring TotalCare Or call us and we will send you a copy

(HMO SNP) you must be entitled to of the provider and pharmacy directories

Medicare Part A be enrolled in Medicare Part B and Texas Medicaid and live in our

What do we cover service area

Like all Medicare health plans we cover Our service area includes the following

everything that Original Medicare covers - counties in Texas Angelina Brazoria

and more Cameron Chambers El Paso Fort Bend Galveston Hardin Harris Hidalgo bull Our plan members get all of Jasper Jefferson Liberty Montgomery the benefits covered by Original Nacogdoches Newton Orange Polk San Medicare Jacinto Tyler Walker Waller Webb and

bull Our plan members also get Willacy more than what is covered by denotes partial county (77510 77511 Original Medicare Some of the 77517 77518 77539 77546 77549 extra benefits are outlined in 77563 77565 77568 77573 77574 this booklet 77590 77591 77592)

We cover Part D drugs In addition How will I determine my drug costs we cover Part B drugs such as

The amount you pay for drugs depends on chemotherapy and some drugs

the drug you are taking and what stage of administered by your provider

the benefit you have reached Later in this bull You can see the complete plan document we discuss the benefit stages

formulary (list of Part D that occur after you meet your deductible prescription drugs) and any Initial Coverage Coverage Gap and restrictions on our website Catastrophic Coverage httpwwwcignahealthspringcom

bull Or call us and we will send you a copy

of the formulary

SECTION II - SUMMARY OF BENEFITS

Benefit Cigna-HealthSpring TotalCare (HMO SNP)

Monthly Premium Deductible and Limits on How Much You Pay for Covered Services

How much is the $2800 per month In addition you must keep paying your Medicare Part B monthly premium premium

How much is the deductible $0 to $74 per year for Part D prescription drugs

Is there any limit on Yes Like all Medicare health plans our plan protects you by having yearly limits how much I will pay for on your out-of-pocket costs for medical and hospital care my covered services In this plan you will pay nothing for Medicare-covered services

Refer to the ldquoMedicare amp Yourdquo handbook for Medicare-covered services For Texas Medicaid-covered services refer to the Medicaid Coverage section in this document

Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs

Is there a limit on how Our plan has a coverage limit every year for certain in-network benefits much the plan will pay Contact us for the services that apply

Cigna-HealthSpring is contracted with Medicare for PDP plans HMO and PPO plans in select states and with select State Medicaid programs Enrollment in Cigna-HealthSpring depends on contract renewal


Covered Medical and Hospital Benefits Note Services with a 1 may require prior authorization

Services with a 2 may require a referral from your doctor

Outpatient Care and Services

Acupuncture Not covered

Ambulance1 You pay nothing

Chiropractic Care2 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position) You pay nothing

Dental Services1 Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth) $0 copay

Preventive dental services bull Cleaning (for up to 1 every six months) $0 copay bull Dental x-ray(s) (for up to 1 every year) $0 copay bull Oral exam (for up to 1 every six months) $0 copay Comprehensive services bull Restorative ndash Fillings Crowns $0 copay bull Periodontics $0 copay bull Extractions $0 copay bull Prosthodontics $0 copay bull Oral Surgery $0 copay

Endodontics is not covered

Please see your EOC for plan coverage details

$1000 plan coverage limit for comprehensive dental benefits every year

Diabetes Supplies and Services2

Diabetes monitoring supplies You pay nothing Diabetes self-management training You pay nothing Therapeutic shoes or inserts You pay nothing

Diagnostic Tests Lab and Radiology Services and X-Rays (Costs for these services may vary based on place of service)12

Diagnostic radiology services (such as MRIs CT scans) You pay nothing Diagnostic tests and procedures You pay nothing Lab services You pay nothing Outpatient x-rays You pay nothing Therapeutic radiology services (such as radiation treatment for cancer) You pay nothing

Doctorrsquos Office Visits12 Primary care physician visit You pay nothing Specialist visit You pay nothing

Durable Medical Equipment (wheelchairs oxygen etc)1

You pay nothing

Emergency Care You pay nothing


Foot Care Foot exams and treatment if you have diabetes-related nerve damage andor (podiatry services)2 meet certain conditions You pay nothing

Hearing Services2 Exam to diagnose and treat hearing and balance issues $0 copay Routine hearing exam (for up to 1 every year) $0 copay Hearing aid fittingevaluation (for up to 1 every three years) $0 copay Hearing aid $0 copay Our plan pays up to $500 every three years for hearing aids Please see your EOC for plan coverage details

Home Health Care1 You pay nothing

Mental Health Care1 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 ldquolifetime reserve daysrdquo These are ldquoextrardquo 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 bull You pay nothing per day for days 1 through 90

Outpatient group therapy visit You pay nothing

Outpatient individual therapy visit You pay nothing

Outpatient Rehabilitation12 Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks) You pay nothing Occupational therapy visit You pay nothing Physical therapy and speech and language therapy visit You pay nothing

Outpatient Group therapy visit You pay nothing Substance Abuse1 Individual therapy visit You pay nothing

Outpatient Surgery12 Ambulatory surgical center You pay nothing Outpatient hospital You pay nothing

Over-the-Counter Items Please visit our website to see our list of covered over-the-counter items Limited to $70 per month for specific over‑the‑counter drugs and other health‑related pharmacy products as listed in the OTC catalog

Prosthetic Devices Prosthetic devices You pay nothing (braces artificial limbs etc)1 Related medical supplies You pay nothing

Renal Dialysis12 You pay nothing


Transportation1 You pay nothing $0 copayment for unlimited one‑way trips to plan‑approved location ever year Please see your EOC for plan coverage details

Urgently Needed Services You pay nothing If you are admitted to the hospital within 24 hours you do not have to pay your share of the cost for urgently needed services See the ldquoInpatient Hospital Carerdquo section of this booklet for other costs

Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening) $0 copay

Routine eye exam (for up to 1 every year) $0 copay

Contact lenses $0 copay

Eyeglasses (frames and lenses) (for up to 1 every year) $0 copay

Eyeglass frames (for up to 1 every year) $0 copay

Eyeglass lenses (for up to 1 every year) $0 copay

Eyeglasses or contact lenses after cataract surgery $0 copay

Our plan pays up to $250 every year for eyewear

$0 copays for supplemental eyewear (except after cataract surgery) apply up to the plan allowance Please see your EOC for plan coverage details


Preventive Care You pay nothing

Our plan covers many preventive services including

bull Abdominal aortic aneurysm screening

bull Alcohol misuse counseling

bull Bone mass measurement

bull Breast cancer screening (mammogram)

bull Cardiovascular disease (behavioral therapy)

bull Cardiovascular screenings

bull Cervical and vaginal cancer screening

bull Colorectal cancer screenings (Colonoscopy Fecal occult blood test Flexible sigmoidoscopy)

bull Depression screening

bull Diabetes screenings

bull HIV screening

bull Medical nutrition therapy services

bull Obesity screening and counseling

bull Prostate cancer screenings (PSA)

bull Sexually transmitted infections screening and counseling

bull Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)

bull Vaccines including Flu shots Hepatitis B shots Pneumococcal shots

bull ldquoWelcome to Medicarerdquo preventive visit (one-time)

bull Yearly ldquoWellnessrdquo visit

Any additional preventive services approved by Medicare during the contract year will be covered

Annual physical exam You pay nothing

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 Hospice is covered outside of our plan Please contact us for more details

Inpatient Care

Inpatient Hospital Care12 Our plan covers an unlimited number of days for an inpatient hospital stay

bull You pay nothing per day for days 1 through 90

bull You pay nothing per day for days 91 and beyond

Inpatient Mental Health Care For inpatient mental health care see the ldquoMental Health Carerdquo section of this booklet

Skilled Nursing Facility (SNF)1

Our plan covers up to 100 days in a SNF



Prescription Drug Benefits

How much do I pay For Part B drugs such as chemotherapy drugs1 You pay nothing Other Part B drugs1 You pay nothing

Initial Coverage Depending on your income and institutional status you pay the following For generic drugs (including brand drugs treated as generic) either

bull $0 copay or bull $120 copay or bull $295 copay

For all other drugs either bull $0 copay or bull $360 copay or bull $740 copay

You may get your drugs at network retail pharmacies and mail order pharmacies

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 at the same cost as an in-network pharmacy

Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4850 you pay nothing for all drugs

Additional Plan Benefits

24-hour Nurse Line $0 copay for 24-hour Nurse Line

Caring registered nurses are available by phone 24 hours a day 7 days a week to answer your health questions in a confidential and convenient service

Fitness $0 copay for membership in Health ClubFitness Classes


Home Safety $1500 allowance once per lifetime for the purchase and installation of approved safety devices in bathrooms Please see your EOC for plan coverage details

This plan is available to anyone who has both Medical Assistance from the State and Medicare For full dual-eligible members the state will continue to pay your Medicare Part B premium Premiums copays co-insurance and deductibles may vary based on the level of Extra Help you receive Please contact the plan for further details

SUMMARY OF MEDICAID-COVERED BENEFITS FOR CONTRACT H4513 PLAN 010

This section demonstrates the Medicaid Medicare Part A and B cost sharing when benefit package for full benefit dual-eligible the state is responsible for paying these recipients in the state of Texas The amounts For more information about your services offered in your Medicaid benefit Medicaid benefits and copayments please package are based on your Medicaid contact the State Medicaid Office eligibility level (Categorically Needy or

The benefits described below are covered Medically Needy) Medicare coverage must

by Medicaid The benefits described in the be used first and the Medicaid Program may

Covered Medical and Hospital Benefits cover payment of Medicare Part A and B

section of the Summary of Benefits are deductible and coinsurance for all Medicare

covered by Medicare For each benefit listed covered services The services listed below

below you can see what Texas Medicaid are available only to those SNP members

covers and what our plan covers What you eligible under Medicaid for medical services

pay for covered services may depend on If you are eligible for both Medicare and

your level of Medicaid eligibility Medicaid you will not be held liable for

Benefit Category (Excludes Medicare-covered services)

Texas Medicaid-covered services

Cigna-HealthSpring TotalCare (HMO SNP)

Important Information

Premium and other important information

Medicaid assistance with premium payment may vary based on your level of Medicaid eligibility

Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for Original Medicare services

$2800 monthly plan premium in addition to your monthly Medicare Part B premium

In-Network

In this plan you will have no cost-sharing responsibility for Medicare-covered services

Doctor and hospital choice (For more information see Emergency Care and Urgently Needed Care)

For those who meet QMB requirements Medicaid pays coinsurance copayments and deductibles for Medicare-covered services Members should follow Medicare guidelines related to hospital and doctor choice

$0 copay for Medicaid-covered services

In-Network

You must go to network doctors specialists and hospitals

Referral required for network hospitals and specialists (for certain benefits)




Inpatient Care

Inpatient Hospital Care (Includes substance abuse and rehabilitation services)

Admissions for the single diagnosis of chemical dependency or abuse without an accompanying medical complication are not a benefit of Texas Medicaid

For Dual-eligible Members Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted


In-Network

Authorization rules may apply

Referral from your Primary Care Physician (PCP) may be required

Our plan covers an unlimited number of days for an inpatient hospital stay



Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital

Inpatient Mental Health Care

Inpatient admissions to acute care hospitals for adults and children for psychiatric conditions are a benefit of Texas Medicaid



In-Network


You get up to 190 days of inpatient psychiatric hospital care in a lifetime Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met This limitation does not apply to inpatient psychiatric services furnished in a general hospital



Skilled Nursing Facility (SNF) (in a Medicare-certified skilled nursing facility)



In-Network







Home Health Care (includes medically necessary intermittent skilled nursing care home health aide services and rehabilitation services etc)



In-Network


$0 copay for Medicare-covered home health visits

Hospice For Dual-eligible Members Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted


You must get care from a Medicare-certified hospice

Your plan will pay for a consultative visit before you select hospice

Outpatient Care

Doctor Office Visits For Dual-eligible Members Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted


In-Network



$0 copay for each Medicare-covered primary care doctor visit

$0 copay for each Medicare-covered specialist visit

Chiropractic Services For Dual-eligible Members Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted


In-Network


$0 copay for Medicare-covered chiropractic visits

Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part)

Podiatry Services For Dual-eligible Members Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted


In-Network



$0 copay for Medicare-covered podiatry visits Medicare-covered podiatry visits are for medically-necessary foot care

Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare

(Excludes Medicare-covered services (HMO SNP)

covered services)

Outpatient Mental For Dual-eligible Members Medicaid In-Network Health Care pays for this service if it is not covered Authorization rules may apply

by Medicare or when the Medicare $0 copay for benefit is exhausted bull each Medicare-covered individual $0 copay for Medicaid-covered services

therapy visit

bull each Medicare-covered group therapy visit

$0 copay for Medicare-covered partial hospitalization program services

Outpatient For Dual-eligible Members Medicaid In-Network Substance pays for this service if it is not covered Authorization rules may apply Abuse Care by Medicare or when the Medicare

$0 copay for benefit is exhausted bull each Medicare-covered individual $0 copay for Medicaid-covered services

substance abuse outpatient treatment visit

bull each Medicare-covered group substance abuse outpatient treatment visit

Outpatient For Dual-eligible Members Medicaid In-Network ServicesSurgery pays for this service if it is not covered Authorization rules may apply

by Medicare or when the Medicare Referral from your Primary Care benefit is exhausted Physician (PCP) is required

$0 copay for Medicaid-covered services $0 copay for each Medicare-covered ambulatory surgical center visit

$0 copay for each Medicare-covered outpatient hospital facility visit

Ambulance Services For Dual-eligible Members Medicaid In-Network (medically necessary pays for this service if it is not covered Authorization rules may apply ambulance services) by Medicare or when the Medicare

$0 copay per ground trip benefit is exhausted 0 coinsurance per air trip $0 copay for Medicaid-covered services

Emergency Care For Dual-eligible Members Medicaid $0 copay for Medicare-covered (you may go to any pays for this service if it is not covered emergency room visits emergency room if you by Medicare or when the Medicare $50000 plan coverage limit for reasonably believe you benefit is exhausted supplemental emergency services need emergency care) $0 copay for Medicaid-covered services outside the US and its territories every

year




Urgently Needed Care (this is not emergency care and in most cases is out of the service area)



$0 copay for Medicare-covered urgently-needed-care Visits

If you are admitted to the hospital within 24 hours for the same condition you pay $0 for the urgently-needed-care visit

Outpatient Rehabilitation Services (occupational therapy physical therapy speech and language therapy)



In-Network



Medically necessary physical therapy occupational therapy and speech and language pathology services are covered

$0 copay for Medicare-covered Occupational Therapy visits

$0 copay for Medicare-covered Physical Therapy and or Speech and Language Pathology visits

Outpatient Medical Services and Supplies

Durable Medical Equipment (includes wheelchairs oxygen etc)



In-Network


$0 copay for Medicare-covered durable medical equipment



covered services)

Prosthetic Devices For Dual-eligible Members under age 21 In-Network (includes braces (CCP) Medicaid pays for this service if it Authorization rules may apply artificial limbs is not covered by Medicare or when the

$0 copay for Medicare-covered and eyes etc) Medicare benefit is exhausted bull prosthetic devices For all Dual-eligible Members Medicaid

pays for breast prostheses if not covered bull medical supplies related to prosthetics by Medicare or when the Medicare splints and other devices benefit is exhausted Quantity limitations apply and vary with each device Prior authorization will NOT be required within limitations except for miscellaneous codes


Diabetes Programs For Dual-eligible Members Medicaid In-Network and Supplies pays for this service if it is not covered Authorization rules may apply

by Medicare or when the Medicare Referral from your Primary Care benefit is exhausted Physician (PCP) may be required

$0 copay for Medicaid-covered services $0 copay for Medicare-covered Diabetes self-management training

$0 copay for Medicare-covered

bull Diabetes monitoring supplies

bull Therapeutic shoes or inserts

Diabetic Supplies and Services are limited to specific manufacturers products andor brands Contact the plan for a list of covered supplies

Diagnostic Tests For Dual-eligible Members Medicaid In-Network X-rays Lab Services pays for this service if it is not covered Authorization rules may apply and Radiology by Medicare or when the Medicare

Referral from your Primary Care Services benefit is exhausted Physician (PCP) may be required

$0 copay for Medicaid-covered services $0 copay for Medicare-covered

bull lab services

bull diagnostic procedures and tests

bull X-rays

bull diagnostic radiology services (not including X-rays)

bull therapeutic radiology services




Cardiac and Pulmonary Rehabilitation Services

Outpatient cardiac rehabilitation is covered for members meeting specific diagnostic criteria for a limited number of sessions



In-Network



Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks) You pay nothing $0 copay for Medicare-covered Pulmonary Rehabilitation Services

Preventive Services

Preventive Services bull Bone Mass Measurement Texas Medicaid covers only the Single Photon Absorptiometry Test


bull Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam for women with Medicare) For Dual-eligible Members Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted


bull Colorectal Cancer Screening (for people with Medicare age 50 and older) For Dual-eligible Members Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted


bull Immunization (Flu vaccine Hepatitis B Vaccine for people with Medicare who are at risk Pneumonia vaccine) For Dual-eligible Members Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted




$0 copay for all preventive services covered under Original Medicare at zero cost sharing

Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare

Plan covers a physical exam annually



covered services)

Preventive Services bull Health Wellness Education (Written (continued) health education materials including

Newsletters Nutritional Training Additional Smoking Cessation other wellness benefits) This is not a Texas Medicaid benefit but is available in some of the pilot programs like the Diabetes and Asthma projects For Dual-eligible Members participating in the Diabetes and Asthma pilot program Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted


bull Mammograms (Annual Screening ndash for women with Medicare age 40 and older) For Dual-eligible Members Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted


bull Physical Exams For Dual-eligible Members Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted


bull Prostate Cancer Screening Exams (for men with Medicare age 50 and older) For Dual-eligible Members Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted


bull Telemedicine Services For Dual-eligible Members Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted




covered services)

Preventive Services Assistive Communication Devices This (continued) is a benefit for clients in an ICF-MR For

Dual-eligible Members who meet the above criteria Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted


Kidney Disease 0 or 20 coinsurance for renal dialysis In-Network and Conditions 0 or 20 coinsurance for kidney Authorization rules may apply

disease education services Referral by your Primary Care Physician (PCP) may be required

$0 copay for Medicare-covered renal dialysis

$0 copay for Medicare-covered kidney disease education services



covered services)

Outpatient For Dual-eligible Members Medicaid Drugs covered under Medicare Part B Prescription Drugs pays for this service if it is not covered $0 yearly deductible for Medicare Part B

by Medicare or when Medicare benefit is drugs exhausted

$0 copay for Medicare Part B drugs $0 copayment for Medicaid-covered

Drugs covered under Medicare Part D prescription drugs not covered by Medicare Part D In-Network

Deductible $0 to $74 per year for Part D prescription drugs

Initial Coverage

Depending on your income and institutional status you pay the following

For generic drugs (including brand drugs treated as generic) either bull A $0 copay or bull A $120 copay or bull A $295 copay

For all other drugs either bull A $0 copay or bull A $360 copay or bull A $740 copay

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4850 you pay nothing for all drugs



covered services)

Dental Services This is a benefit only for Texas Health In-Network Steps eligible clients and for clients in an Authorization rules may apply ICF-MR who are 21 years of age and

Referral from your Primary Care older For Dual-eligible Members who Physician (PCP) may be required meet the above criteria Medicaid pays

for this service if it is not covered by $0 copay for Medicare-covered dental Medicare or when the Medicare benefit benefits is exhausted $0 copay for the following preventive $0 copay for Medicaid-covered services dental benefits

bull up to 1 oral exam(s) every six months bull up to 1 cleaning(s) every six months bull up to 1 dental X-ray every year

$0 copay for the following comprehensive services bull Restorative ndash Fillings Crowns bull Periodontics bull Extractions bull Prosthodontics bull Oral Surgery




Hearing Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered Referral by your Primary Care Physician by Medicare or when the Medicare (PCP) may be required benefit is exhausted

Exam to diagnose and treat hearing and $0 copay for Medicaid-covered services balance issues $0 copay

Routine hearing exam (for up to 1 every year) $0 copay Hearing aid fittingevaluation (for up to 1 every three years) $0 copay Hearing aid $0 copay Our plan pays up to $500 every three years for hearing aids




covered services)

Vision Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered $0 copay for Medicare-covered by Medicare or when the Medicare diagnosis and treatment for diseases benefit is exhausted and conditions of the eye including an $0 copay for Medicaid-covered services annual glaucoma screening for people at

risk

$0 copay for up to 1 supplemental routine eye exam every year

$0 copay for

bull one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery

bull up to 1 pair of eyeglasses (lenses and frames) every year

bull contact lenses

bull up to 1 pair of eyeglass lenses every year

bull up to 1 eyeglass frame(s) every year

$250 plan coverage limit for eyewear every year


WellnessEducation 24 hour Nurse Advice Hotline Texas In-Network and other Medicaid Wellness Program The plan covers the following Supplemental supplemental educationwellness Benefits and Services programs

bull 24 Hour Nurse Line

bull Gym membership

Over-the- Not covered Please visit our website to see our list of Counter Items covered over-the-counter items

Limited to $70 per month for specific over‑the‑counter drugs and other health‑related pharmacy products as listed in the OTC catalog



covered services)

Transportation For Dual-eligible Members the Medicaid In-Network (routine) Medical Transportation provides this Authorization rules may apply

service if it is not covered by Medicare $0 copay for unlimited trip(s) to plan-or when the Medicare benefit is approved locations every year exhausted


Home and Community Based Waiver Services

Those who meet QMB requirements and also meet the financial criteria for full Medicaid coverage may be eligible to receive all Medicaid services not covered by Medicare including waiver services Waiver services are limited to individuals who meet additional waiver eligibility criteria

Community Based For information on waiver services and Not covered Alternatives eligibility for this waiver contact the (CBA) Waiver Department of Aging and Disability

Services (DADS)

Community Living For information on waiver services and Not covered Assistance and eligibility for this waiver contact the Support Services Department of Aging and Disability (CLASS) Waiver Services (DADS)

Consolidated Waiver For information on waiver services and Not covered Program (CWP) - eligibility for this waiver contact the Bexar CountySan Department of Aging and Disability Antonio Only Services (DADS)

Deaf Blind With For information on waiver services and Not covered Multiple Disabilities eligibility for this waiver contact the Waiver (DB-MD) Department of Aging and Disability

Services (DADS)

Home and For information on waiver services and Not covered Community Services eligibility for this waiver contact the (HCS) Waiver Department of Aging and Disability

Services (DADS)

Medically For information on waiver services and Not covered Dependent Children eligibility for this waiver contact the Program (MDCP) Department of Aging and Disability

Services (DADS)



covered services)

Star+Plus Waiver For information on waiver services and Not covered eligibility for this waiver contact the Department of Aging and Disability Services (DADS)

Texas Home Living For information on waiver services and Not covered Waiver (TXHML) eligibility for this waiver contact the

Department of Aging and Disability Services (DADS)


All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation including Cigna Health and Life Insurance Company Cigna HealthCare of South Carolina Inc Cigna HealthCare of North Carolina Inc Cigna HealthCare of Georgia Inc Cigna HealthCare of Arizona Inc Cigna HealthCare of St Louis Inc HealthSpring Life amp Health Insurance Company Inc HealthSpring of Tennessee Inc HealthSpring of Alabama Inc HealthSpring of Florida Inc Bravo Health Mid-Atlantic Inc and Bravo Health Pennsylvania Inc The Cigna name logos and other Cigna marks are owned by Cigna Intellectual Property Inc

SECTION I - INTRODUCTION TO SUMMARY OF BENEFITS

This booklet gives you a summary of what we cover and what you pay It doesnrsquot list every service that we cover or list every limitation or exclusion To get a complete list of services we cover call us and ask for the ldquoEvidence of Coveragerdquo

You have choices about how to get your Medicare benefits

bull One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare) Original Medicare is run directly by the Federal government

bull Another choice is to get your Medicare benefits by joining a Medicare health plan (such as Cigna-HealthSpring TotalCare (HMO SNP))

Tips for comparing your Medicare choices

This Summary of Benefits booklet gives you a summary of what Cigna-HealthSpring TotalCare (HMO SNP) covers and what you pay

bull If you want to compare our plan with other Medicare health plans ask the other plans for their Summary of Benefits booklets Or use the Medicare Plan Finder on httpwwwmedicaregov

Sections in this booklet

bull Things to Know About Cigna-HealthSpring TotalCare (HMO SNP)

bull Monthly Premium Deductible and Limits on How Much You Pay for Covered Services

bull Covered Medical and Hospital Benefits

bull Prescription Drug Benefits

bull If you want to know more about the coverage and costs of Original Medicare look in your current ldquoMedicare amp Yourdquo handbook View it online at httpwwwmedicaregov or get a copy by calling 1-800-MEDICARE (1-800-633-4227) 24 hours a day 7 days a week TTY users should call 1-877-486-2048

This document is available in other formats such as Braille and large print

This document may be available in a non-English language For additional information call us at 1-800-668-3813

Este documento puede estar disponible en un idioma distinto al ingleacutes Para obtener informacioacuten adicional llaacutemenos al 1-800-668-3813


























of the formulary





























You pay nothing











































bull HIV screening












Inpatient Care











































In-Network





In-Network






Inpatient Care





In-Network











In-Network








In-Network










In-Network







Outpatient Care



In-Network







In-Network






In-Network






covered services)



therapy visit














year












In-Network










In-Network





covered services)















bull lab services


bull X-rays










In-Network




Preventive Services
















covered services)














covered services)










covered services)






Initial Coverage







covered services)















covered services)


risk


$0 copay for



bull contact lenses







bull Gym membership





covered services)







Services (DADS)




Services (DADS)


Services (DADS)


Services (DADS)



covered services)































of the formulary





























You pay nothing











































bull HIV screening












Inpatient Care











































In-Network





In-Network






Inpatient Care





In-Network











In-Network








In-Network










In-Network







Outpatient Care



In-Network







In-Network






In-Network






covered services)



therapy visit














year












In-Network










In-Network





covered services)















bull lab services


bull X-rays










In-Network




Preventive Services
















covered services)














covered services)










covered services)






Initial Coverage







covered services)















covered services)


risk


$0 copay for



bull contact lenses







bull Gym membership





covered services)







Services (DADS)




Services (DADS)


Services (DADS)


Services (DADS)



covered services)
























You pay nothing











































bull HIV screening












Inpatient Care











































In-Network





In-Network






Inpatient Care





In-Network











In-Network








In-Network










In-Network







Outpatient Care



In-Network







In-Network






In-Network






covered services)



therapy visit














year












In-Network










In-Network





covered services)















bull lab services


bull X-rays










In-Network




Preventive Services
















covered services)














covered services)










covered services)






Initial Coverage







covered services)















covered services)


risk


$0 copay for



bull contact lenses







bull Gym membership





covered services)







Services (DADS)




Services (DADS)


Services (DADS)


Services (DADS)



covered services)















































bull HIV screening












Inpatient Care











































In-Network





In-Network






Inpatient Care





In-Network











In-Network








In-Network










In-Network







Outpatient Care



In-Network







In-Network






In-Network






covered services)



therapy visit














year












In-Network










In-Network





covered services)















bull lab services


bull X-rays










In-Network




Preventive Services
















covered services)














covered services)










covered services)






Initial Coverage







covered services)















covered services)


risk


$0 copay for



bull contact lenses







bull Gym membership





covered services)







Services (DADS)




Services (DADS)


Services (DADS)


Services (DADS)



covered services)









































In-Network





In-Network






Inpatient Care





In-Network











In-Network








In-Network










In-Network







Outpatient Care



In-Network







In-Network






In-Network






covered services)



therapy visit














year












In-Network










In-Network





covered services)















bull lab services


bull X-rays










In-Network




Preventive Services
















covered services)














covered services)










covered services)






Initial Coverage







covered services)















covered services)


risk


$0 copay for



bull contact lenses







bull Gym membership





covered services)







Services (DADS)




Services (DADS)


Services (DADS)


Services (DADS)



covered services)









Inpatient Care





In-Network











In-Network








In-Network










In-Network







Outpatient Care



In-Network







In-Network






In-Network






covered services)



therapy visit














year












In-Network










In-Network





covered services)















bull lab services


bull X-rays










In-Network




Preventive Services
















covered services)














covered services)










covered services)






Initial Coverage







covered services)















covered services)


risk


$0 copay for



bull contact lenses







bull Gym membership





covered services)







Services (DADS)




Services (DADS)


Services (DADS)


Services (DADS)



covered services)












In-Network







Outpatient Care



In-Network







In-Network






In-Network






covered services)



therapy visit














year












In-Network










In-Network





covered services)















bull lab services


bull X-rays










In-Network




Preventive Services
















covered services)














covered services)










covered services)






Initial Coverage







covered services)















covered services)


risk


$0 copay for



bull contact lenses







bull Gym membership





covered services)







Services (DADS)




Services (DADS)


Services (DADS)


Services (DADS)



covered services)








covered services)



therapy visit














year












In-Network










In-Network





covered services)















bull lab services


bull X-rays










In-Network




Preventive Services
















covered services)














covered services)










covered services)






Initial Coverage







covered services)















covered services)


risk


$0 copay for



bull contact lenses







bull Gym membership





covered services)







Services (DADS)




Services (DADS)


Services (DADS)


Services (DADS)



covered services)

















In-Network










In-Network





covered services)















bull lab services


bull X-rays










In-Network




Preventive Services
















covered services)














covered services)










covered services)






Initial Coverage







covered services)















covered services)


risk


$0 copay for



bull contact lenses







bull Gym membership





covered services)







Services (DADS)




Services (DADS)


Services (DADS)


Services (DADS)



covered services)








covered services)















bull lab services


bull X-rays










In-Network




Preventive Services
















covered services)














covered services)










covered services)






Initial Coverage







covered services)















covered services)


risk


$0 copay for



bull contact lenses







bull Gym membership





covered services)







Services (DADS)




Services (DADS)


Services (DADS)


Services (DADS)



covered services)













In-Network




Preventive Services
















covered services)














covered services)










covered services)






Initial Coverage







covered services)















covered services)


risk


$0 copay for



bull contact lenses







bull Gym membership





covered services)







Services (DADS)




Services (DADS)


Services (DADS)


Services (DADS)



covered services)








covered services)














covered services)










covered services)






Initial Coverage







covered services)















covered services)


risk


$0 copay for



bull contact lenses







bull Gym membership





covered services)







Services (DADS)




Services (DADS)


Services (DADS)


Services (DADS)



covered services)








covered services)










covered services)






Initial Coverage







covered services)















covered services)


risk


$0 copay for



bull contact lenses







bull Gym membership





covered services)







Services (DADS)




Services (DADS)


Services (DADS)


Services (DADS)



covered services)








covered services)






Initial Coverage







covered services)















covered services)


risk


$0 copay for



bull contact lenses







bull Gym membership





covered services)







Services (DADS)




Services (DADS)


Services (DADS)


Services (DADS)



covered services)








covered services)















covered services)


risk


$0 copay for



bull contact lenses







bull Gym membership





covered services)







Services (DADS)




Services (DADS)


Services (DADS)


Services (DADS)



covered services)








covered services)


risk


$0 copay for



bull contact lenses







bull Gym membership





covered services)







Services (DADS)




Services (DADS)


Services (DADS)


Services (DADS)



covered services)








covered services)







Services (DADS)




Services (DADS)


Services (DADS)


Services (DADS)



covered services)








covered services)






SUMMARY OF BENEFITS - Cigna · This Summary of Benefits booklet ... as listed in the OTC catalog....

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Transcript of SUMMARY OF BENEFITS - Cigna · This Summary of Benefits booklet ... as listed in the OTC catalog....