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Summary of BenefitsJanuary 1, 2022 toDecember 31, 2022Cigna Preferred Medicare (HMO)H4513-049-001COVERAGE2022 0 monthly plan premium; no referrals requiredTo Join1 About this planYou must be entitled to Medicare Part A, be enrolled inMedicare Part B and live in our service area.2 Monthly Premium,Deductible and Limits3 Covered Medical andHospital Benefits4 Prescription DrugBenefitsH4513 22 98920 MService AreaTennessee: Bedford, Benton, Bledsoe, Bradley, Cannon,Carroll, Chester, Clay, Coffee, Crockett, Cumberland,Davidson, Decatur, DeKalb, Fayette, Fentress, Franklin,Gibson, Giles, Grundy, Hamilton, Hardeman, Hardin,Haywood, Henderson, Henry, Houston, Humphreys, Jackson,Lake, Lauderdale, Lawrence, Lewis, Lincoln, Macon, Madison,Marion, Marshall, Maury, McNairy, Moore, Obion, Overton,Perry, Pickett, Polk, Putnam, Rutherford, Sequatchie, Shelby,Smith, Stewart, Sumner, Tipton, Trousdale, Van Buren,Warren, Wayne, Weakley, White, Williamson and Wilsoncounties, TN22 S H4513 049 0011Cigna Preferred Medicare (HMO) H4513-049-001What’s Inside
IntroductionCOVERAGEThis Summary of Benefits gives you a summary of what Cigna PreferredMedicare (HMO) covers and what you pay. It doesn’t list every servicethat we cover or list every limitation or exclusion. To get a complete listof services we cover, refer to the plan’s Evidence of Coverage (EOC)online at CignaMedicare.com, or call us to request a copy.Comparing coverageNeed help?If you want to compare our plan with otherMedicare health plans, ask the other plansfor their Summary of Benefits. Or, use theMedicare Plan Finder on www.medicare.gov.Already a customerCigna Preferred Medicare (HMO) H4513-049-001More about Original MedicareIf you want to know more about the coverageand costs of Original Medicare, look in yourcurrent Medicare & You handbook.View the handbook online at:www.medicare.govGet a copy of the handbook by calling:1-800-MEDICARE (1-800-633-4227),24 hours a day, 7 days a week. TTY usersshould call 1-877-486-2048.Call toll‑free 1-800-668-3813 (TTY 711).Customer Service is available October 1 toMarch 31, 8 a.m. to 8 p.m. local time, 7 daysa week. From April 1 to September 30,Monday to Friday 8 a.m. to 8 p.m. local time.Our automated phone system may answeryour call during weekends, holidays andafter hours.Not a customerCall toll‑free 1-866-593-4468 (TTY 711),licensed agents are available October 1 toMarch 31, 8 a.m. to 8 p.m. local time, 7 daysa week. From April 1 to September 30,Monday to Friday 8 a.m. to 8 p.m. local time.Our automated phone system may answeryour call during weekends, holidays andafter hours.You can also visit our website at:CignaMedicare.com2
1 About this PlanWhich doctors, hospitals andpharmacies can I use?Like all Medicare health plans, we covereverything that Original Medicarecovers—and more.You must generally use network pharmaciesto fill your prescriptions for coveredPart D drugs.› Our customers get all of the benefitscovered by Original Medicare.› Our customers also get more than whatis covered by Original Medicare. Someof the extra benefits are outlined in thisSummary of Benefits.› You can see our plan’s Providerand Pharmacy Directory at ourwebsite, CignaMedicare.com.We cover Part D drugs. In addition, we coverPart B drugs such as chemotherapy andsome drugs administered by your provider.Cigna Preferred Medicare (HMO) H4513-049-001› You can see the plan’s completeComprehensive Prescription Drug Listwhich lists the Part D prescriptiondrugs along with any restrictions on ourwebsite, CignaMedicare.com.› Or, call us and we will send you a copyof the plan’s Comprehensive PrescriptionDrug List.COVERAGECigna Preferred Medicare (HMO) has anetwork of doctors, hospitals, pharmaciesand other providers. If you use the providersthat are not in our network, the plan maynot pay for these services.What do we cover?3
COVERAGE2 Monthly Premium, Deductibleand LimitsBenefitCigna Preferred Medicare (HMO)Monthly Premium 0 per month. In addition, you must keep paying your MedicarePart B premium.Medical DeductibleThis plan does not have a deductiblePharmacy (Part D) DeductibleThis plan does not have a deductibleIs there any limit on howmuch I will pay for mycovered services?Original Medicare does not have annual limits on out-of-pocket costs.Your yearly limit(s) in this plan: 5,900 for services you receive from in-network providers forMedicare-covered benefits.This limit is the most you pay for copays, coinsurance and other costs forMedicare services for the year. If you reach the limit on out-of-pocket costs,you will keep getting in-network covered hospital and medical services andwe will pay the full cost for the rest of the year.Cigna Preferred Medicare (HMO) H4513-049-001Please note that you will still need to pay your monthly premiums and costsharing for your Part D prescription drugs.4
3 Covered Medical andHospital BenefitsBenefitWhat You PayNote: Services with a ¹ may require prior authorization.Services with a ² may require a referral from your doctor.Inpatient Hospital Coverage1 325 per day for days 1–5COVERAGEExcept in an emergency, your doctor must tellthe plan that you are going to be admitted tothe hospital. 0 per day for days 6–90For each Medicare-covered hospital stay, you arerequired to pay the applicable cost-sharing, startingwith Day 1 each time you are admitted.There is a 0 copayment per lifetime reserve day.Outpatient Surgery 0– 275 copayOutpatient Services1 0– 300 copayOutpatient Observation1 275 per stayCigna Preferred Medicare (HMO) H4513-049-001Ambulatory Surgical Center (ASC)1Doctors VisitsPrimary Care Physician (PCP) 0 copaySpecialists1 5 copay5
BenefitWhat You PayCigna Preferred Medicare (HMO) H4513-049-001COVERAGEPreventive CareOur plan covers many Medicare-coveredpreventive services, including:› Abdominal aortic aneurysm screening› Alcohol misuse screenings and counseling› Bone mass measurement› Breast cancer screening (mammogram)› Cardiovascular disease (behavioral therapy)› Cardiovascular screenings› Cervical and vaginal cancer screening› Colorectal cancer screening (colonoscopy,fecal occult blood test, multi-target stoolDNA tests, screening barium enemas,flexible sigmoidoscopy)› Depression screenings› Diabetes screenings› Diabetes self-management training› Glaucoma tests› Hepatitis B Virus (HBV) infection screening› Hepatitis C screening› HIV screening› Lung cancer screening with low dose computedtomography (LDCT)› Medical nutrition therapy services› Obesity screening and counseling› Prostate cancer screenings (PSA)› Sexually transmitted infections screeningand counseling› Smoking and tobacco use cessation counseling(counseling for people with no sign oftobacco-related disease)› Vaccines; including COVID-19, Flu shots,Hepatitis B shots and Pneumococcal shots› Welcome to Medicare preventive visit (one-time)› Yearly Wellness visit 0 copayAny additional preventive services approved byMedicare during the contract year will be covered.Please see your Evidence of Coverage (EOC) forfrequency of covered services.Emergency CareEmergency Care Services 90 copayIf you are admitted to the hospital within 24 hours for thesame condition, you do not have to pay your share ofthe cost for emergency care.Worldwide Emergency/UrgentCoverage/Emergency Transportation6 90 copayMaximum worldwide coverage amount 50,000
BenefitWhat You PayUrgently Needed ServicesUrgent Care Services 30 copayIf you are admitted to the hospital within 24 hours for thesame condition, you do not have to pay your share ofthe cost for urgent care.Diagnostic Services, Labs and ImagingCosts for these services may vary based on place of service or type of serviceDiagnostic Procedures and Tests1 0– 150 copayLab Services1 0 copayFor COVID-19 testing a prior authorization isnot required.20% coinsuranceX-ray Services 0– 50 copayDiagnostic Radiological Services (MRIs, CTscans, etc.)1 0– 150 copayCOVERAGETherapeutic Radiological Services1Hearing ServicesHearing Exams (Medicare-covered) 5 copayRoutine Hearing Exams 0 copay for one routine exam every yearHearing Aid Evaluation/Fitting 0 copay for one hearing aid fitting evaluation everythree yearsHearing Aids 0 copay up to plan maximum coverage amountfor hearing aids of 700 per ear per device everythree yearsCigna Preferred Medicare (HMO) H4513-049-001A separate physician cost-share will applyif additional services requiring cost-sharingare rendered.7
BenefitWhat You PayDental Services (Medicare-covered)1Limited dental services (this does not includeservices in connection with care, treatment, filling,removal or replacement of teeth) 5 copayPreventive and Comprehensive Dental ServicesDental Allowance 0 copay up to allowance amountSupplemental dental services with licenseddentist.* Provider submits claim to Cigna DentalHealth. Includes Preventive and ComprehensiveServices. Benefit does not cover cosmetic services. 1,500 combined Preventive and Comprehensiveallowance every yearCigna Preferred Medicare (HMO) H4513-049-001COVERAGE*Dentist is not on the exclusion/preclusion list, and/or who has not opted out of Medicare.Vision ServicesEye Exams (Medicare-covered) 0 copay for diabetic retinopathy screeningA separate physician cost-share will applyif additional services requiring cost-sharingare rendered. A facility cost-share may applyfor procedures performed at an outpatientsurgical center. 5 copay for all other Medicare-covered vision servicesRoutine Eye Exam 0 copay for one routine exam every yearGlaucoma Screening (Medicare-covered) 0 copayEyewear (Medicare-covered) 0 copayRoutine EyewearContact lensesEyeglasses-lenses and framesEyeglass lensesEyeglass framesUpgrades 0 copay up to plan maximum coverage amount of 200every year›››››8The plan specified allowance may be applied to oneset of the member’s choice of eyewear once per year,to include the eyeglass frame/lenses/lens optionscombination or contact lenses (to include relatedprofessional fees) in lieu of eyeglasses.
BenefitWhat You PayMental Health ServicesInpatient1 325 per day for days 1–5Except in an emergency, your doctor must tellthe plan that you are going to be admitted tothe hospital. 0 per day for days 6–90For each Medicare-covered hospital stay, you arerequired to pay the applicable cost-sharing, startingwith Day 1 each time you are admitted.There is a 0 copayment per lifetime reserve day.Outpatient1 0 copayIndividual or Group Therapy VisitOur plan covers up to 100 days in the SNF.COVERAGESkilled Nursing Facility (SNF)1 0 per day for days 1–20 184 per day for days 21–100Rehabilitation Services 10 copayPulmonary Rehab Services1 10 copayOccupational Therapy Services1 30 copayPhysical Therapy, Speech and LanguageTherapy Services1 30 copayPhysical Therapy, Speech and Language TherapyTelehealth Services1 0 copayCigna Preferred Medicare (HMO) H4513-049-001Cardiac (Heart) Rehab Services1Ambulance1Ground Service (one-way trip) 250 copayAir Service (one-way trip)20% coinsuranceTransportationNot CoveredPrescription Drugs1Medicare Part B Drugs20% coinsuranceMedicare-covered Part B Drugs may be subject tostep therapy requirements.This plan has Part D prescription drug coverage. SeeSection 4 in the Summary of Benefits.Foot Care (Podiatry Services)Podiatry Services (Medicare-covered) 5 copayRoutine Podiatry ServicesNot Covered9
BenefitWhat You PayMedical Equipment and SuppliesDurable Medical Equipment (wheelchairs,oxygen, etc.)120% coinsuranceProsthetic Devices (braces, artificial limbs, etc.)and Related Medical Supplies120% coinsuranceDiabetes Supplies and Services1 0 copay for diabetes self-management trainingBrand limitations apply to certain supplies.20% coinsurance for therapeutic shoes or inserts0% or 20% coinsurance for diabetic monitoring suppliesFitness and Wellness ProgramsCigna Preferred Medicare (HMO) H4513-049-001COVERAGEFitness Program 0 copayThe program offers the flexibility of a fitness centermembership, digital fitness tools, and a homefitness kit.Health Information LineTalk one-on-one with a Nurse Advocate* to gettimely answers to your health-related questions atno additional cost, anytime day or night. 0 copay*Nurse Advocates hold current nursing licensurein a minimum of one state, but are not practicingnursing or providing medical advice in any capacityas a health advocate.Chiropractic Care1Chiropractic Services (Medicare-covered) 5 copayRoutine Chiropractic ServicesNot CoveredHome Health1 0 copayHospiceHospice care must be provided by a Medicarecertified hospice program. 0 copayOur plan covers hospice consultation services(one-time only) before you select hospice. Hospiceis covered outside of our plan. You may have topay part of the cost for drugs and respite care.Please contact the plan for more details.Outpatient Substance Abuse1Individual or Group Therapy Visit10 30 copay
BenefitWhat You PayOpioid Treatment Services1FDA-approved treatment medications in addition totesting, counseling and therapy. 30 copayOver-the-Counter Items (OTC)Over-the-counter drugs and other health-relatedpharmacy products, as listed in the OTC Catalog. 35 quarterly allowanceHome Delivered Meals1 0 copayment for home delivered mealsCOVERAGELimited to 14 meals per discharge from a qualifiedhospital stay or skilled nursing facility (up to three staysper year), ESRD care management is limited to 56meals per benefit period.**Authorization and/or referral applies to ESRD meals.Telehealth Services (Medicare-covered)For nonemergency care, talk with a telehealthdoctor via phone or video for certain telehealthservices, including: allergies, cough, headache,sore throat, and other minor illnesses. 0 copayAcupuncture Services 5 copayCigna Preferred Medicare (HMO) H4513-049-001Acupuncture Services (Medicare-covered)1Services for chronic lower back pain.Supplemental Acupuncture ServicesNot CoveredAdditional BenefitsEnjoy these extra benefits included in your plan.Annual Physical Exam 0 copay11
4 Prescription Drug BenefitsMedicare Part D DrugsInitial CoverageCOVERAGEThe following charts show the cost‑sharingamounts for covered drugs under this plan.After you pay your yearly Part D deductible,you pay the following until your total yearlydrug costs reach 4,430. Total yearly drugcosts are the total drug costs paid by bothyou and our plan.You may get your drugs at preferred orstandard network retail pharmacies, orpreferred mail order pharmacies. Yourprescription drug copay will typically be lessat a preferred network pharmacy because ithas a preferred agreement with your plan.You can get your prescription from anout‑of‑network pharmacy, but may paymore than you would pay at an in‑networkpharmacy. If you reside in a long term carefacility, you would pay the standard retailcost‑sharing at an in‑network pharmacy.Your costs may be different if you qualifyfor Extra Help. Your copay or coinsuranceis based on the drug tier for yourmedication, which you can find in the planComprehensive Prescription Drug Liston our website CignaMedicare.com. Or,call us and we will send you a copy of theComprehensive Prescription Drug List.Cigna Preferred Medicare (HMO) H4513-049-001Mail Order Cost-SharingTierTier 1Preferred Generic DrugsTier 2Generic DrugsTier 3Preferred Brand DrugsTier 4Non-Preferred DrugsTier 5Specialty dayPreferred 0 0 0 5 10 0 42 84 12650%50%50%33%Not AvailableNot AvailableStandard 10 20 30 20 40 60 47 94 14150%50%50%33%Not AvailableNot AvailableRetail Cost-SharingPreferred 0 0 0 5 10 10 42 84 12650%50%50%33%Not AvailableNot AvailableStandard 10 20 30 20 40 60 47 94 14150%50%50%33%Not AvailableNot Available
Coverage GapCatastrophic CoverageMost Medicare prescription drug plans havea Coverage Gap (also called the DonutHole). This means that there is a temporarychange in what you will pay for your drugs.The Coverage Gap begins after your totalyearly prescription drug cost (includingwhat our plan has paid and what you havepaid) reaches 4,430. Not everyone willenter the Coverage Gap.You qualify for the Catastrophic CoverageStage when your out‑of‑pocket costshave reached the 7,050 limit for thecalendar year. Once you are in theCatastrophic Coverage Stage, you will stayin this payment stage until the end of thecalendar year.› Coinsurance of 5% of the cost of thedrug, or› 3.95 for a generic drug or a drug thatis treated like a generic and 9.85 for allother drugs.– Our plan pays the rest of the cost.COVERAGEAfter you enter the Coverage Gap, youpay 25% of the plan’s cost for coveredbrand name drugs and 25% of the plan’scost for covered generic drugs until yourcosts total 7,050, which is the end of theCoverage Gap.Your share of the cost of covered drugs willbe the greater of:Cigna Preferred Medicare (HMO) H4513-049-00113
14Cigna Preferred Medicare (HMO) H4513-049-001COVERAGE
Medicare (HMO) covers and what you pay. It doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, refer to the plan's . Evidence of Coverage (EOC) online at CignaMedicare.com, or call us to request a copy. Cigna Preferred Medicare (HMO) H4513-049-001 . Comparing coverage
