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Cigna True Choice Medicare (PPO) - H7849-029-000
$0.00
Monthly Premium
Cigna True Choice Medicare (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Cigna
Plan ID: H7849-029-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
Utah Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.
Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.
Learn more about Utah Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $0.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $0.00 |
| Out-of-pocket maximum | $4,300.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,000.00 |
| Primary care doctor visit | In Network In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 Out of Network Out-of-Network: Doctor Office Visit Services: Copayment for Medicare Covered Primary Care Office Visit $25 |
| Specialty doctor visit | In Network In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $30 Prior Authorization Required for Doctor Specialty Visit Out of Network Out-of-Network: Doctor Specialty Visit Services: Copayment for Medicare Covered Physician Specialist Office Visit $65 |
| Inpatient hospital care | In Network In-Network: Acute Hospital Services: $305 per day for days 1 to 5 $0 per day for days 6 to 90 Prior Authorization Required for Acute Hospital Services In some instances, a readmission policy may apply in which the benefit will continue from original admission. Out of Network Out-of-Network: Acute Hospital Services: Coinsurance for Acute Hospital Services per Stay 40% In some instances, a readmission policy may apply in which the benefit will continue from original admission. |
| Urgent care | Urgent Care: Copayment for Urgent Care $30 Copayment for Medicare Covered Urgent Care waived if you are admitted to hospital within 2 hours Worldwide Coverage: Copayment for Worldwide Urgent Coverage $125 Maximum Plan Benefit of $50,000 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $125 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $125 Copayment for Worldwide Emergency Transportation $125 Maximum Plan Benefit of $50,000 |
| Ambulance transportation | In Network In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $160 Air Ambulance: Coinsurance for Air Ambulance Services 20% Prior Authorization Required for Air Ambulance Out of Network Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $160 Coinsurance for Medicare Covered Ambulance Services - Ground 20% Copayment for Medicare Covered Ambulance Services - Air $160 Coinsurance for Medicare Covered Ambulance Services - Air 20% |
Health Care Services and Medical Supplies
Cigna True Choice Medicare (PPO) covers a range of additional benefits. Learn more about Cigna True Choice Medicare (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | In Network In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $15 Prior Authorization Required for Chiropractic Services Out of Network Out-of-Network: Medicare Covered Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 50% |
| Diabetes supplies, training, nutrition therapy and monitoring | In Network In-Network: Diabetic Supplies and Services: Copayment for Medicare-covered Diabetic Supplies $0 Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 15% Out of Network Out-of-Network: Medicare Covered Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies 40% Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 40% |
| Durable medical equipment (DME) | In Network In-Network: Durable Medical Equipment: Coinsurance for Medicare-covered Durable Medical Equipment 15% Prior Authorization Required for Durable Medical Equipment Out of Network Out-of-Network: Medicare Covered Durable Medical Equipment Services: Coinsurance for Medicare Covered Durable Medical Equipment 40% |
| Diagnostic tests, lab and radiology services, and X-rays | In Network In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0 to $25 Copayment for Medicare-covered Lab Services $0 to $50 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Minimum for EKG. Maximum for all other diagnostic procedures and tests. Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0 to $250 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $0 to $15 If multiple test types (e.g. CT and PET) are performed on the same day, multiple copayments will apply. If multiple tests of the same type (e.g. CT scan of the head and CT scan of the chest) are performed on the same day, one copayment will apply. Out of Network Out-of-Network: Medicare Covered Diagnostic Procedures/Tests Services: Coinsurance for Medicare Covered Diagnostic Procedures/Tests 40% Coinsurance for Medicare Covered Lab Services 40% Coinsurance for Medicare Covered Diagnostic Radiological Services 40% Coinsurance for Medicare Covered Therapeutic Radiological Services 40% Coinsurance for Medicare Covered Outpatient X-Ray Services 40% Minimum for EKG. Maximum for all other diagnostic procedures and tests. |
| Home health care | In Network In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services Out of Network Out-of-Network: Medicare Covered Home Health Services: Coinsurance for Medicare Covered Home Health 40% |
| Mental health inpatient care | In Network In-Network: Psychiatric Hospital Services: $305 per day for days 1 to 5 $0 per day for days 6 to 90 Prior Authorization Required for Psychiatric Hospital Services In some instances, a readmission policy may apply in which the benefit will continue from original admission. Out of Network Out-of-Network: Psychiatric Hospital Services: Coinsurance for Psychiatric Hospital per Stay 40% In some instances, a readmission policy may apply in which the benefit will continue from original admission. |
| Mental health outpatient care | In Network In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $0 Copayment for Medicare-covered Group Sessions $0 Out of Network Out-of-Network: Medicare Covered Mental Health Services: Coinsurance for Medicare Covered Individual Sessions 50% Coinsurance for Medicare Covered Group Sessions 50% |
| Outpatient services/surgery | In Network In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $305 Prior Authorization Required for Outpatient Hospital Services Minimum for any surgical procedures (e.g. polyp removal) during a colorectal screening. Maximum for all other outpatient services not provided in an Ambulatory Surgical Center. Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $305 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 to $275 Prior Authorization Required for Ambulatory Surgical Center Services Minimum for any surgical procedures (e.g. polyp removal) during a colorectal screening. Maximum for all other Ambulatory Surgical Center (ASC) services. Out of Network Out-of-Network: Medicare Covered Outpatient Hospital Services: Coinsurance for Medicare Covered Outpatient Hospital Services 40% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 40% Minimum for any surgical procedures (e.g. polyp removal) during a colorectal screening. Maximum for all other outpatient services not provided in an Ambulatory Surgical Center. |
| Outpatient substance abuse care | In Network In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $30 Copayment for Medicare-covered Group Sessions $30 Prior Authorization Required for Outpatient Substance Abuse Services Out of Network Out-of-Network: Medicare Covered Outpatient Substance Abuse Services: Copayment for Medicare Covered Individual Sessions $65 Copayment for Medicare Covered Group Sessions $65 |
| Over-the-counter items | In Network In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0
Catalog orders limited to one per member per month. Exceptions may apply. Out of Network Out-of-Network: Non-Medicare Covered Over-The-Counter (OTC) Items Services: Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0
|
| Podiatry services | In Network In-Network: Medicare Covered Podiatry Services: Copayment for Medicare-Covered Podiatry Services $30 Out of Network Out-of-Network: Medicare Covered Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 50% |
| Skilled Nursing Facility (SNF) care | In Network In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $214 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services In some instances, a readmission policy may apply in which the benefit will continue from original admission. Out of Network Out-of-Network: Skilled Nursing Facility Services: $200 per day for days 1 to 30 $0 per day for days 31 to 100 In some instances, a readmission policy may apply in which the benefit will continue from original admission. |
Dental Benefits
The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Dental care | In Network In-Network: Preventive Dental: Copayment for Office Visit $30 Prior Authorization Required for Preventive Dental Comprehensive Dental: Copayment for Non-routine Services $0 Copayment for Diagnostic Services $0 Copayment for Restorative Services $0 Copayment for Endodontics $0 Copayment for Periodontics $0 Copayment for Extractions $0 Maximum Plan Benefit of $1,100 every year Out of Network Out-of-Network: Medicare Covered Preventive Dental Services: Copayment for Medicare Covered Preventive Dental $65 |
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage
| Coverage | Details |
|---|---|
| Vision care | In Network In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0 to $30 Copayment for Routine Eye Exams $0
Eyewear: Copayment for Medicare-Covered Benefits $0 Copayment for Contact Lenses $0 Copayment for Eyeglasses (lenses and frames) $0
Maximum Plan Benefit of $100 every year Corrective lenses, frames and contacts are covered once per year. The plan will not cover both corrective lenses/frames and contacts in the same benefit year. Out of Network Out-of-Network: Medicare Covered Eye Exams Services: Coinsurance for Medicare Covered Eye Exams 50% Coinsurance for Medicare Covered Eyewear 40% |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | In Network In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $30 Copayment for Routine Hearing Exams $0
Hearing Aids: Copayment for Hearing Aids $399 to $1800
Out of Network Out-of-Network: Medicare Covered Hearing Exams Services: Coinsurance for Medicare Covered Hearing Exams 50% |
Preventive Services and Health/Wellness Education Programs
The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Preventive services and health/wellness education programs | In Network In-Network: $0.00 copay for Medicare Covered Preventive Services: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginal cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Shots:
Yearly "Wellness" visit Out of Network Out-of-Network: Medicare Covered Medicare-covered Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $25 |
When reviewing Utah Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.
You may be able to find plans in your part of Utah that offer similar benefits at similar or lower prices than the plan above. Call 1-888-876-5731 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Plan Documents
| Links to plan documents |
Utah Counties Served
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.