cigna healthcare of arizona medicare advantage … · cigna healthcare of arizona medicare...

Cigna HealthCare of Arizona

Medicare Advantage Employer Group Plans

2017BENEFIT OPTION M3P1 (M1 non-std)P2

Region Arizona Arizona

Plan Name 4153-Cigna Companies 4173-Citi

Contract and ID # H0354-804 H0354-804

Plan Type HMO HMO

Account Renewal Status Confirmed Confirmed

Section A Counties Maricopa, Pinal (Partial) Maricopa, Pinal (Partial)

N/A In/Out of Network Indicator INN INN

N/A Total Premium

N/A Optional Supplemental Premium - Package 1

N/A N/A


N/A N/A

N/A Part B Premium Buy Down N/A N/A

Section C Max Plan Coverage Amount for OON N/A N/A

Section C

Does this POS benefit service the United States

and its territories?

N/A N/A

Section C

Does this POS benefit include all practitioners

who are state-licensed or state-certified to

furnish the services?

N/A N/A

Section D Maximum Out-of-Pocket Cost (MOOP)

$5,500 which applies to in-network Medicare-

covered and in-network non-Medicare-

covered benefits



covered benefits

Section D Part A/B deductible N/A N/A

1A IP-Acute Cost Sharing Varying by Hospital No No

1A Number of Tiers for IP-Acute (Max of 3) 1 1

1A Lowest Tier of Cost Sharing for IP-Acute 1 1

1A IP-Acute cost sharing $150 per day for days 1-7

$0 per day for days 8-90

$500 per admission

1A IP-Acute Additional Days Yes; Unlimited Yes; Unlimited

1A

Medicare defined benefit period applies to IP-

Acute cost sharing

No No

1A

Other benefit period applies to IP-Acute cost

sharing

No No

1A

Cost sharing applies on day of IP-Acute

discharge

No No

1B IP-Psychiatric Cost Sharing Varying by Hospital

No No

1B Number of Tiers for IP-Psychiatric (Max of 3)

1 1

1B Lowest Tier of Cost Sharing for IP-Psychiatric

1 1

1B

IP-Psychiatric cost sharing

-includes stays in the psych wing of an acute hospital

-includes inpatient substance abuse treatment

(Lifetime days limit does not apply to mental

health/substance abuse stays in a psych wing of an

acute hospital.)



190 days lifetime maximum

$500 per admission


1B IP-Psychiatric Additional Days Not covered Not covered

1B


Psychiatric cost sharing

No No

1B

Other benefit period applies to IP-Psychiatric

cost sharing

No No

1B

Cost sharing applies on day of IP-Psychiatric

discharge

No No

2 Skilled Nursing Facility (SNF) $0 per day for days 1-20




2 SNF Additional Days Not covered Not covered

2

Medicare defined benefit period applies to SNF

cost sharing

Yes Yes

2

Other benefit period applies to SNF cost

sharing

Yes Yes

2 Cost sharing applies on day of SNF discharge

No No

3 Cardiac Rehab services $30 $30

3 Intensive Cardiac Rehab services $30 $30

3 Pulmonary Rehab services $30 $30

4A ER $75 $75

4A

Days or Hours within which admission must

occur for ER copay to be waived

24 Hours 24 Hours

4B Urgently Needed Services $25 $20

4B


occur for Urgently Needed Services copay to be

waived

24 Hours 24 Hours

4C Worldwide Emergency/Urgent Coverage $75 $75

4C

Does this benefit include emergency

transportation?

Yes, Emergency transportation must be

medically necessary.



4C

Maximum Coverage amount for ER- Worldwide

Coverage

$50,000 $50,000

4C

Is the service-specific Maximum Plan Benefit

Coverage amount unlimited?

No No

4C

Is this copay waived for worldwide coverage if

admitted to the hospital?

Yes Yes

5

Partial Hospitalization (includes intensive outpatient

mental health treatment-auth required)

$30 $40

6 Home Health $0 $0

7A Primary Care Physician $0 $0

7B Chiropractic (Medicare Covered) $20 $20

PBP Category

of 20







Plan Type HMO HMO


PBP Category

7B Routine Chiropractic$20 per visit for up to 12 routine visits per

year

$20 per visit for up to 12 routine visits per

year

7C Occupational Therapy $30 $25

7D Physician Specialist $30 $25

7E

Mental Health-Individual sessions (includes intensive

outpatient mental health treatment-auth required)

$30 $25

7E

Mental Health-Group sessions (includes intensive


$30 $25

7F Podiatry (Medicare Covered) $30 $25

7F Routine Podiatry $30 $25

7G

Other Health Care (Physician Assistants, Nurse

Practitioners, etc..)In PCP office - $0

In Specialist office - $30

In PCP office - $0


7H Psychiatric-Individual $30 $25

7H Psychiatric-Group $30 $25

7I PT and SP $30 $25

8A Diagnostic Procedures/Tests $0 $0

8A Lab Services $0 $0

8B Diagnostic Radiological Services (MRI, CT, PET)

mammography and ultrasound-$0

CMG/ASC/HospOP - $125

non-cardiac nuclear studies - $0

cardiac nuclear studies - $30





routine stress test - $25

8B Therapeutic Radiological Services (radiation therapy)$0 $25

8B X-Ray Services $0 $0

9A Hospital Outpatient Services

$0 for colorectal screenings

$30 for HospOP nonSurgical

$100 for HospOP Surgical




9B Ambulatory Surgical Center (ASC)

$0 for colorectal screenings.

$75 for all other CMG & contracted ASC

facility services.


All else-$175

9C

OP Substance Abuse-Individual (includes intensive

outpatient treatment-auth required)$30 $25

9C

OP Substance Abuse-Group (includes intensive

outpatient treatment-auth required)$30 $25

9D Outpatient Blood Services$0 with deductible waived for first three pints $0

10A Ambulance - Ground $200 $150

10A Ambulance - Air $200 $150

10B Transportation Not covered Not covered

11A DME

POV, scooters, power wheelchairs, air

fluidized beds - $100

all other DME-$0


fluidized beds - 20%

all other DME-$0

11B Prosthetics $0 $0

11B Medical Supplies $0 $0

11C

Diabetic Supplies

Coverage of meters and supplies is limited to

preferred manufacturers. Non-preferred brand

diabetic test strips & monitors are not covered.

Members are eligible for one glucose monitor

every two years and 200 glucose test strips per

30-day period. (Not applicable for Lacera)

$0 $0

11C Diabetic Therapeutic Shoes or Inserts $0 $0

12 Renal Dialysis $30 $25

13A Acupuncture and Other Therapies Not covered Not covered

13B OTC Items (Max Monthly Coverage) Not covered Not covered

13B

Does unused max coverage amount carry

forward to next period?

Not covered Not covered

13C Meal Benefit Not covered Not covered

13C How many weeks does your Meal Benefit last?


13C

What is the maximum number of meals the

benefit provides?


13D/E/F Home Safety Devices benefit (max coverage)


13D/E/F Healthy Rewards/Choices Not covered Not covered

13D/E/F Additional Medical Nutritional Therapy Not covered Not covered

14A Medicare Covered Preventive services $0 $0

14B Annual Physical Exam Not covered Not covered

14C Health Education Not covered Not covered

14C Nutritional/Dietary Benefit* Not covered Not covered

14C Additional Smoking & Tobacco Use Cessation


14C Fitness Benefit* (Silver & Fit) $0 $0

14C Enhanced Disease Management Not covered Not covered

14C Tele-Monitoring Services* Not covered Not covered

14C

Remote Access Technologies (including Web/

Phone Based Technologies & Nursing Hotline)*

$0 $0

14C Bathroom Safety Devices* Not covered Not covered

14C Counseling Services Not covered Not covered

14C In-Home Safety Assessment Not covered Not covered

of 20







Plan Type HMO HMO


PBP Category

14C Personal Emergency Response System (PERS)


14C Medical Nutrition Therapy (MNT) Not covered Not covered

14C

Post discharge In-home Medication

Reconciliation


14C Re-admission Prevention Not covered Not covered

14C Wigs for Hair Loss Related to Chemotherapy


14C Weight Management Programs Not covered Not covered

14C Alternative Therapies* Not covered Not covered

14D Kidney Disease Education Services $0 $0

14E Glaucoma Screening $0 $0

14E Diabetes Self Management Training $0 $0

15

Part B Drugs Including Chemotherapy Drugs and

Office Injectables

Flu and Pneumonia shots - $0

Hepatitis B shots - $0

Oral Part B Drugs - 20%

Chemotherapy drugs - $0

Office Injectables - $0

SVN Meds - $0

All Other Part B - $0






SVN Meds - $0


15

Provide Part D home infusion drugs as part

of a bundled service under Part C

Yes Yes

16 Type of Dental Benefit Not covered Not covered

16A Preventive Dental Benefit


16A

Maximum Coverage Amount for Preventive

Dental


16B Comprehensive Dental Benefit


16B

Comp Dental: Non-routine Services Cost

Sharing


16B Comp Dental: Diagnostic Services Cost Sharing


16B

Comp Dental: Restorative Services Cost

Sharing


16B

Comp Dental:

Endodontics/Periodontics/Extractions Cost

Sharing


16B

Comp Dental: Prosthodontics, Other

Oral/Maxillofacial Surgery, Other Services Cost

Sharing


16B

Maximum Coverage Amount for

Comprehensive Dental


16B Comprehensive Dental (Medicare-Covered)

$30 $25

17A Eye Exams (Medicare covered)

$0 for diabetic retinal exams

$30 for all other Medicare-covered vision

services



services

17A Routine Eye Exams $0 for one routine exam every year $0 for one routine exam every year

17A

Maximum Coverage Amount for Routine Eye

Exams

No max plan coverage amount No max plan coverage amount

17B Eye wear (Medicare covered) $0 $0

17B Routine Eye Wear Coverage

Contact Lenses: unlimited

Eye Glasses (Lenses and Frames): one

every year

Eye Glass Lenses: one every year

Eye Glass Frames: one every year



every year



17B

Max Coverage Amount for Routine Eye Wear

Coverage

$50 every year $50 every year

18A Hearing Exams (Medicare covered) $30 $25

18A Routine Hearing Exams $0 $0

18A Fitting/Evaluation for Hearing Aids $0 $0

18A Max Coverage for Routine Hearing Exams No max plan coverage amount No max plan coverage amount

18B Hearing Aids Frequency Unlimited Unlimited

18B Maximum Coverage for Hearing Aids $200 per unit $200 per unit

Section Rx Part D OPTION P1 OPTION P2

Section Rx Type of Benefit-Part D Defined Standard with Wrap Defined Standard with Wrap

Section Rx Formulary Formulary 5 Cigna Formulary 5 Cigna

Section Rx Does plan utilize floor pricing? No No

Section Rx Does plan utilize ceiling pricing? No No

Section Rx Number of Tiers 5 5

Section Rx Formulary Exception Tier 4 4

Section Rx Part D deductible amount $0 $0

Section Rx ICL amount Standard Part D ICL Amount -$3700 Standard Part D ICL Amount -$3700

of 20







Plan Type HMO HMO


PBP Category

Section Rx Tier Label Description

Tier 1: Preferred Generic

Tier 2: Generic

Tier 3: Preferred Brand

Tier 4: Non-Preferred Drug

Tier 5: Specialty


Tier 2: Generic



Tier 5: Specialty

Section Rx Tier Drug Types


Tier 2: Generic

Tier 3: Non-Preferred Generic and Preferred

Brand

Tier 4: Non-Preferred Generic and Non-

Preferred Brand

Tier 5: Generic and Brand


Tier 2: Generic


Brand


Preferred Brand


Section Rx

Standard Retail Pharmacy Cost Share – Daily

Supply

Tier 1: $0.16

Tier 2: $0.50

Tier 3: $1.40

Tier 4: $3.17

Tier 1: $0.00

Tier 2: $0.33

Tier 3: $1.50

Tier 4: $3.17

Section Rx

Standard Retail Pharmacy Cost Share – One

Month Supply

Tier 1: $5

Tier 2: $15

Tier 3: $42

Tier 4: $95

Tier 5: 33%

Tier 1: $0

Tier 2: $10

Tier 3: $45

Tier 4: $95

Tier 5: 33%

Section Rx

Standard Retail Pharmacy Cost Share – Two

Month Supply

Tier 1: $10

Tier 2: $30

Tier 3: $84

Tier 4: $190

Tier 5: Not Available

Tier 1: $0

Tier 2: $20

Tier 3: $90

Tier 4: $190


Section Rx

Standard Retail Pharmacy Cost Share – Three

Month Supply

Tier 1: $15

Tier 2: $45

Tier 3: $126

Tier 4: $285


Tier 1: $0

Tier 2: $30

Tier 3: $135

Tier 4: $285


of 20







Plan Type HMO HMO


PBP Category

Section Rx

Preferred Retail Pharmacy Cost Share – Daily

supply

Tier 1: $

Tier 2: $

Tier 3: $

Tier 4: $

Tier 1: $

Tier 2: $

Tier 3: $

Tier 4: $

Section Rx

Preferred Retail Pharmacy Cost Share – One

Month Supply

Tier 1: $

Tier 2: $

Tier 3: $

Tier 4: $

Tier 1: $

Tier 2: $

Tier 3: $

Tier 4: $

Section Rx

Preferred Retail Pharmacy Cost Share – Two

Month Supply

Tier 1: $

Tier 2: $

Tier 3: $

Tier 4: $

Tier 1: $

Tier 2: $

Tier 3: $

Tier 4: $

Section Rx

Preferred Retail Pharmacy Cost Share – Three

Month Supply

Tier 1: $

Tier 2: $

Tier 3: $

Tier 4: $

Tier 1: $

Tier 2: $

Tier 3: $

Tier 4: $

Section Rx Retail Pharmacy days supply

30 days for one month supply

60 days for two month supply

90 days for three month supply

(60 and 90 day excludes Tier 5)





Section Rx

Standard Mail Order Pharmacy Cost Share –

Daily Supply

Tier 1: $0.16

Tier 2: $0.50

Tier 3: $1.40

Tier 4: $3.17

Tier 1: $0.00

Tier 2: $0.33

Tier 3: $1.50

Tier 4: $3.17

Section Rx

Standard Mail Order Pharmacy Cost Share -

One Month Supply

Tier 1: $5

Tier 2: $15

Tier 3: $42

Tier 4: $95

Tier 5: 33%

Tier 1: $0

Tier 2: $10

Tier 3: $45

Tier 4: $95

Tier 5: 33%

Section Rx


Three Month Supply

Tier 1: $15

Tier 2: $45

Tier 3: $126

Tier 4: $285


Tier 1: $0

Tier 2: $30

Tier 3: $135

Tier 4: $285


Section Rx Standard Mail Order Pharmacy Days Supply

30 days for a one month supply


(90 day excludes Tier 5)




Section Rx Out of Network Pharmacy Cost Share

Tier 1: $5

Tier 2: $15

Tier 3: $42

Tier 4: $95

Tier 5: 33%

Tier 1: $0

Tier 2: $10

Tier 3: $45

Tier 4: $95

Tier 5: 33%

Section Rx Out of Network Pharmacy Days Supply 30 days for one month supply 30 days for one month supply

Section Rx LTC Pharmacy Cost Share – Daily Supply

Tier 1: $0.00

Tier 2: $0.48

Tier 3: $1.35

Tier 4: $3.06

Tier 1: $0.00

Tier 2: $0.32

Tier 3: $1.45

Tier 4: $3.06

Section Rx LTC Pharmacy Cost Share – One Month Supply

Tier 1: $5

Tier 2: $15

Tier 3: $42

Tier 4: $95

Tier 5: 33%

Tier 1: $0

Tier 2: $10

Tier 3: $45

Tier 4: $95

Tier 5: 33%

Section Rx LTC Pharmacy days supply 31 days for one month supply 31 days for one month supply

Section Rx Gap coverage Not covered All tiers: Full coverage

Section Rx OOP Threshhold TypeMedicare-defined post threshold cost shares -

$4950

Medicare-defined post threshold cost shares -

$4950

Section Rx OOP Threshhold Tiers All Tiers All Tiers

of 20



2017BENEFIT OPTION

Region

Plan Name

Contract and ID #

Plan Type

Account Renewal Status

Section A Counties

N/A In/Out of Network Indicator

N/A Total Premium



N/A Part B Premium Buy Down

Section C Max Plan Coverage Amount for OON

Section C



Section C





Section D Part A/B deductible

1A IP-Acute Cost Sharing Varying by Hospital

1A Number of Tiers for IP-Acute (Max of 3)

1A Lowest Tier of Cost Sharing for IP-Acute

1A IP-Acute cost sharing

1A IP-Acute Additional Days

1A


Acute cost sharing

1A


sharing

1A


discharge




1B






acute hospital.)

1B IP-Psychiatric Additional Days

1B



1B


cost sharing

1B


discharge

2 Skilled Nursing Facility (SNF)

2 SNF Additional Days

2


cost sharing

2


sharing


3 Cardiac Rehab services

3 Intensive Cardiac Rehab services

3 Pulmonary Rehab services

4A ER

4A



4B Urgently Needed Services

4B



waived

4C Worldwide Emergency/Urgent Coverage

4C


transportation?

4C


Coverage

4C



4C



5



6 Home Health

7A Primary Care Physician

7B Chiropractic (Medicare Covered)

PBP Category

M3P3 M4P3

Arizona Arizona

4178-City of New York 4100-Honeywell

H0354-804 H0354-804

HMO HMO

Confirmed Confirmed

Maricopa, Pinal (Partial) Maricopa, Pinal (Partial)

INN INN

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A



covered benefits



covered benefits

N/A N/A

No No

1 1

1 1



$0 per admission

Yes; Unlimited Yes; Unlimited

No No

No No

No No

No No

1 1

1 1




$0 per admission



No No

No No

No No






Yes Yes

Yes Yes

No No

$30 $12

$30 $12

$30 $12

$75 $75

24 Hours 24 Hours

$25 $25

24 Hours 24 Hours

$75 $75





$50,000 $50,000

No No

Yes Yes

$30 $12

$0 $0

$0 $0

$20 $12

of 20



2017BENEFIT OPTION

Region

Plan Name

Contract and ID #

Plan Type


PBP Category

7B Routine Chiropractic

7C Occupational Therapy

7D Physician Specialist

7E



7E



7F Podiatry (Medicare Covered)

7F Routine Podiatry

7G


Practitioners, etc..)

7H Psychiatric-Individual

7H Psychiatric-Group

7I PT and SP

8A Diagnostic Procedures/Tests

8A Lab Services


8B Therapeutic Radiological Services (radiation therapy)

8B X-Ray Services



9C


outpatient treatment-auth required)

9C



9D Outpatient Blood Services

10A Ambulance - Ground

10A Ambulance - Air

10B Transportation

11A DME

11B Prosthetics

11B Medical Supplies

11C

Diabetic Supplies







11C Diabetic Therapeutic Shoes or Inserts

12 Renal Dialysis

13A Acupuncture and Other Therapies

13B OTC Items (Max Monthly Coverage)

13B



13C Meal Benefit


13C


benefit provides?


13D/E/F Healthy Rewards/Choices

13D/E/F Additional Medical Nutritional Therapy

14A Medicare Covered Preventive services

14B Annual Physical Exam

14C Health Education

14C Nutritional/Dietary Benefit*


14C Fitness Benefit* (Silver & Fit)

14C Enhanced Disease Management

14C Tele-Monitoring Services*

14C



14C Bathroom Safety Devices*

14C Counseling Services

14C In-Home Safety Assessment

M3P3 M4P3

Arizona Arizona


H0354-804 H0354-804

HMO HMO

Confirmed Confirmed


year


year

$30 $12

$30 $12

$30 $12

$30 $12

$30 $12

$30 $12

In PCP office - $0


In PCP office - $0


$30 $12

$30 $12

$30 $12

$0 $0

$0 $0


GMG/ASC/HospOP - $125








$0 $12

$0 $0





All else-$12


All else-$75


All else-$12

$30 $12

$30 $12

$0 with deductible waived for first three pints $0 with deductible waived for first three pints

$200 $0

$200 $0



fluidized beds - $100

all other DME-$0

$0

$0 $0

$0 $0

$0 $0

$0 $0

$30 $12










$0 $0





$0 $0



$0 $0




of 20



2017BENEFIT OPTION

Region

Plan Name

Contract and ID #

Plan Type


PBP Category


14C Medical Nutrition Therapy (MNT)

14C


Reconciliation

14C Re-admission Prevention


14C Weight Management Programs

14C Alternative Therapies*

14D Kidney Disease Education Services

14E Glaucoma Screening

14E Diabetes Self Management Training

15


Office Injectables

15



16 Type of Dental Benefit


16A


Dental


16B


Sharing


16B


Sharing

16B

Comp Dental:


Sharing

16B



Sharing

16B





17A Routine Eye Exams

17A


Exams

17B Eye wear (Medicare covered)


17B


Coverage

18A Hearing Exams (Medicare covered)

18A Routine Hearing Exams

18A Fitting/Evaluation for Hearing Aids

18A Max Coverage for Routine Hearing Exams

18B Hearing Aids Frequency

18B Maximum Coverage for Hearing Aids

Section Rx Part D

Section Rx Type of Benefit-Part D

Section Rx Formulary

Section Rx Does plan utilize floor pricing?

Section Rx Does plan utilize ceiling pricing?

Section Rx Number of Tiers

Section Rx Formulary Exception Tier

Section Rx Part D deductible amount

Section Rx ICL amount

M3P3 M4P3

Arizona Arizona


H0354-804 H0354-804

HMO HMO

Confirmed Confirmed








$0 $0

$0 $0

$0 $0






SVN Meds - $0







SVN Meds - $0


Yes Yes

Not covered Preventive and Comprehensive Dental

Not covered Oral exam: four every year

Cleaning: two every year

Bitewing x-ray: one every year

Full mouth & panoramic x-ray: one every

three years

$5 per office visit - see notes for other cost

sharing

Not covered

No max plan coverage amount

Not covered Diagnostic Services: unlimited;

Restorative Services: unlimited;

Endodontics/Periodontics/Extractions:

unlimited;

Prosthodontics/Oral Surgery: unlimited;

Not covered

Not covered

Not covered

$0-$240

Not covered

$0-$115

Not covered

$12-$430

Not covered

$0-$2,376

Not covered

No max plan coverage amount

$30 $12



services



services

$0 for one routine exam every year $0 for one routine exam every year


$0 $0



every year





every year




$30 $12

$0 $0

$0 $0


Unlimited Unlimited

$200 per unit $200 per unit

OPTION P3 OPTION P3

Defined Standard with Wrap Defined Standard with Wrap

Formulary 5 Cigna Formulary 5 Cigna

No No

No No

5 5

4 4

$0 $0

Standard Part D ICL Amount -$3700 Standard Part D ICL Amount -$3700

of 20



2017BENEFIT OPTION

Region

Plan Name

Contract and ID #

Plan Type


PBP Category



Section Rx


Supply

Section Rx


Month Supply

Section Rx


Month Supply

Section Rx


Month Supply

M3P3 M4P3

Arizona Arizona


H0354-804 H0354-804

HMO HMO

Confirmed Confirmed


Tier 2: Generic



Tier 5: Specialty


Tier 2: Generic



Tier 5: Specialty


Tier 2: Generic


Brand


Preferred Brand



Tier 2: Generic


Brand


Preferred Brand


Tier 1: $0.00

Tier 2: $0.16

Tier 3: $1.00

Tier 4: $1.00

Tier 5: $1.00

Tier 1: $0.00

Tier 2: $0.16

Tier 3: $1.00

Tier 4: $1.00

Tier 5: $1.00

Tier 1: $0

Tier 2: $5

Tier 3: $30

Tier 4: $30

Tier 5: $30

Tier 1: $0

Tier 2: $5

Tier 3: $30

Tier 4: $30

Tier 5: $30

Tier 1: $0

Tier 2: $10

Tier 3: $60

Tier 4: $60


Tier 1: $0

Tier 2: $10

Tier 3: $60

Tier 4: $60


Tier 1: $0

Tier 2: $15

Tier 3: $90

Tier 4: $90


Tier 1: $0

Tier 2: $15

Tier 3: $90

Tier 4: $90


of 20



2017BENEFIT OPTION

Region

Plan Name

Contract and ID #

Plan Type


PBP Category

Section Rx


supply

Section Rx


Month Supply

Section Rx


Month Supply

Section Rx


Month Supply


Section Rx


Daily Supply

Section Rx


One Month Supply

Section Rx


Three Month Supply



Section Rx Out of Network Pharmacy Days Supply



Section Rx LTC Pharmacy days supply

Section Rx Gap coverage

Section Rx OOP Threshhold Type

Section Rx OOP Threshhold Tiers

M3P3 M4P3

Arizona Arizona


H0354-804 H0354-804

HMO HMO

Confirmed Confirmed

Tier 1: $

Tier 2: $

Tier 3: $

Tier 4: $

Tier 1: $

Tier 2: $

Tier 3: $

Tier 4: $

Tier 1: $

Tier 2: $

Tier 3: $

Tier 4: $

Tier 1: $

Tier 2: $

Tier 3: $

Tier 4: $

Tier 1: $

Tier 2: $

Tier 3: $

Tier 4: $

Tier 1: $

Tier 2: $

Tier 3: $

Tier 4: $

Tier 1: $

Tier 2: $

Tier 3: $

Tier 4: $

Tier 1: $

Tier 2: $

Tier 3: $

Tier 4: $









Tier 1: $0.00

Tier 2: $0.16

Tier 3: $1.00

Tier 4: $1.00

Tier 5: $1.00

Tier 1: $0.00

Tier 2: $0.16

Tier 3: $1.00

Tier 4: $1.00

Tier 5: $1.00

Tier 1: $0

Tier 2: $5

Tier 3: $30

Tier 4: $30

Tier 5: $30

Tier 1: $0

Tier 2: $5

Tier 3: $30

Tier 4: $30

Tier 5: $30

Tier 1: $0

Tier 2: $15

Tier 3: $90

Tier 4: $90


Tier 1: $0

Tier 2: $15

Tier 3: $90

Tier 4: $90








Tier 1: $0

Tier 2: $5

Tier 3: $30

Tier 4: $30

Tier 5: $30

Tier 1: $0

Tier 2: $5

Tier 3: $30

Tier 4: $30

Tier 5: $30

30 days for one month supply 30 days for one month supply

Tier 1: $0.00

Tier 2: $0.16

Tier 3: $0.97

Tier 4: $0.97

Tier 5: $0.97

Tier 1: $0.00

Tier 2: $0.16

Tier 3: $0.97

Tier 4: $0.97

Tier 5: $0.97

Tier 1: $0

Tier 2: $5

Tier 3: $30

Tier 4: $30

Tier 5: $30

Tier 1: $0

Tier 2: $5

Tier 3: $30

Tier 4: $30

Tier 5: $30


All tiers: Full coverage All tiers: Full coverage


$4950


$4950

All Tiers All Tiers

of 20



2017BENEFIT OPTION

Region

Plan Name

Contract and ID #

Plan Type


Section A Counties


N/A Total Premium





Section C



Section C











1A


Acute cost sharing

1A


sharing

1A


discharge




1B






acute hospital.)


1B



1B


cost sharing

1B


discharge



2


cost sharing

2


sharing





4A ER

4A




4B



waived


4C


transportation?

4C


Coverage

4C



4C



5



6 Home Health



PBP Category

(M4 non-std) (P2 non-std) M4P2

Arizona Arizona

4225-Lockheed 4108-Salt River Project

H0354-804 H0354-804

HMO HMO

Confirmed Confirmed


INN INN

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A



covered benefits



covered benefits

N/A N/A

No No

1 1

1 1

$250 Per day up to $1,000 Max per

Confinement

$0 per admission


No No

No No

No No

No No

1 1

1 1

$250 per day up to $1,000 max per

confinement


$0 per admission



No No

No No

No No






Yes Yes

Yes Yes

No No

$12 $12

$12 $12

$12 $12

$75 $75

24 Hours 24 Hours

$25 $25

24 Hours 24 Hours

$75 $75





$50,000 $50,000

No No

Yes Yes

$12 $12

$0 $0

$0 $0

$12 $12

of 20



2017BENEFIT OPTION

Region

Plan Name

Contract and ID #

Plan Type


PBP Category




7E



7E




7F Routine Podiatry

7G





7I PT and SP


8A Lab Services



8B X-Ray Services



9C



9C





10A Ambulance - Air

10B Transportation

11A DME

11B Prosthetics


11C

Diabetic Supplies








12 Renal Dialysis



13B



13C Meal Benefit


13C


benefit provides?












14C







Arizona Arizona


H0354-804 H0354-804

HMO HMO

Confirmed Confirmed


year


year

$12 $12

$12 $12

$12 $12

$12 $12

$12 $12

$12 $12

In PCP office - $0


In PCP office - $0


$12 $12

$12 $12

$12 $12

$0 $0

$0 $0











$12 $12

$0 $0


All else-$12


All else-$12


All else-$12


All else-$12

$12 $12

$12 $12


$0 $0

$0 $0


$0 $0

$0 $0

$0 $0

$0 $0

$0 $0

$12 $12










$0 $0





$0 $0



$0 $0




of 20



2017BENEFIT OPTION

Region

Plan Name

Contract and ID #

Plan Type


PBP Category



14C


Reconciliation








15


Office Injectables

15





16A


Dental


16B


Sharing


16B


Sharing

16B

Comp Dental:


Sharing

16B



Sharing

16B






17A


Exams



17B


Coverage







Section Rx Part D










Arizona Arizona


H0354-804 H0354-804

HMO HMO

Confirmed Confirmed








$0 $0

$0 $0

$0 $0






SVN Meds - $0







SVN Meds - $0


Yes Yes











$12 $12



services



services



$0 $0



every year





every year




$12 $12

$0 $0

$0 $0


Unlimited Unlimited


Non-Standard OPTION P2



No No

No No

5 5

4 4

$0 $0


of 20



2017BENEFIT OPTION

Region

Plan Name

Contract and ID #

Plan Type


PBP Category



Section Rx


Supply

Section Rx


Month Supply

Section Rx


Month Supply

Section Rx


Month Supply


Arizona Arizona


H0354-804 H0354-804

HMO HMO

Confirmed Confirmed


Tier 2: Generic



Tier 5: Specialty


Tier 2: Generic



Tier 5: Specialty


Tier 2: Generic


Brand


Preferred Brand



Tier 2: Generic


Brand


Preferred Brand


Tier 1: $0.10

Tier 2: $0.33

Tier 3: $1.00

Tier 4: $1.00

Tier 5: $1.00

Tier 1: $0.00

Tier 2: $0.33

Tier 3: $1.50

Tier 4: $3.17

Tier 1: $3

Tier 2: $10

Tier 3: $30

Tier 4: $30

Tier 5: $30

Tier 1: $0

Tier 2: $10

Tier 3: $45

Tier 4: $95

Tier 5: 33%

Tier 1: $6

Tier 2: $20

Tier 3: $60

Tier 4: $60


Tier 1: $0

Tier 2: $20

Tier 3: $90

Tier 4: $190


Tier 1: $9

Tier 2: $30

Tier 3: $90

Tier 4: $90


Tier 1: $0

Tier 2: $30

Tier 3: $135

Tier 4: $285


of 20



2017BENEFIT OPTION

Region

Plan Name

Contract and ID #

Plan Type


PBP Category

Section Rx


supply

Section Rx


Month Supply

Section Rx


Month Supply

Section Rx


Month Supply


Section Rx


Daily Supply

Section Rx


One Month Supply

Section Rx


Three Month Supply











Arizona Arizona


H0354-804 H0354-804

HMO HMO

Confirmed Confirmed

Tier 1: $

Tier 2: $

Tier 3: $

Tier 4: $

Tier 1: $

Tier 2: $

Tier 3: $

Tier 4: $

Tier 1: $

Tier 2: $

Tier 3: $

Tier 4: $

Tier 1: $

Tier 2: $

Tier 3: $

Tier 4: $

Tier 1: $

Tier 2: $

Tier 3: $

Tier 4: $

Tier 1: $

Tier 2: $

Tier 3: $

Tier 4: $

Tier 1: $

Tier 2: $

Tier 3: $

Tier 4: $

Tier 1: $

Tier 2: $

Tier 3: $

Tier 4: $









Tier 1: $0.10

Tier 2: $0.33

Tier 3: $1.00

Tier 4: $1.00

Tier 5: $1.00

Tier 1: $0.00

Tier 2: $0.33

Tier 3: $1.50

Tier 4: $3.17

Tier 1: $3

Tier 2: $10

Tier 3: $30

Tier 4: $30

Tier 5: $30

Tier 1: $0

Tier 2: $10

Tier 3: $45

Tier 4: $95

Tier 5: 33%

Tier 1: $9

Tier 2: $30

Tier 3: $90

Tier 4: $90


Tier 1: $0

Tier 2: $30

Tier 3: $135

Tier 4: $285








Tier 1: $3

Tier 2: $10

Tier 3: $30

Tier 4: $30

Tier 5: $30

Tier 1: $0

Tier 2: $10

Tier 3: $45

Tier 4: $95

Tier 5: 33%


Tier 1: $0.10

Tier 2: $0.32

Tier 3: $0.97

Tier 4: $0.97

Tier 5: $0.97

Tier 1: $0.00

Tier 2: $0.32

Tier 3: $1.45

Tier 4: $3.06

Tier 1: $3

Tier 2: $10

Tier 3: $30

Tier 4: $30

Tier 5: $30

Tier 1: $0

Tier 2: $10

Tier 3: $45

Tier 4: $95

Tier 5: 33%




$4950


$4950

All Tiers All Tiers

of 20



2017BENEFIT OPTION

Region

Plan Name

Contract and ID #

Plan Type


Section A Counties


N/A Total Premium





Section C



Section C











1A


Acute cost sharing

1A


sharing

1A


discharge




1B






acute hospital.)


1B



1B


cost sharing

1B


discharge



2


cost sharing

2


sharing





4A ER

4A




4B



waived


4C


transportation?

4C


Coverage

4C



4C



5



6 Home Health



PBP Category

M4P2 M4P2

Arizona Arizona

4185-Viad

4123-Lacera

Contract Jul 1, 2016 - Jun 30, 2017

H0354-804 H0354-805

HMO HMO

Confirmed Confirmed


INN INN

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A



covered benefits



covered benefits

N/A N/A

No No

1 1

1 1

$0 per admission $0 per admission


No No

No No

No No

No No

1 1

1 1

$0 per admission


$0 per admission



No No

No No

No No






Yes No

Yes Yes

No No

$12 $12

$12 $12

$12 $12

$75 $75

24 Hours 24 Hours

$25 $25

24 Hours 24 Hours

$75 $75





$50,000 No max plan coverage amount

No Yes

Yes Yes

$12 $12

$0 $0

$0 $0

$12 $12

of 20



2017BENEFIT OPTION

Region

Plan Name

Contract and ID #

Plan Type


PBP Category




7E



7E




7F Routine Podiatry

7G





7I PT and SP


8A Lab Services



8B X-Ray Services



9C



9C





10A Ambulance - Air

10B Transportation

11A DME

11B Prosthetics


11C

Diabetic Supplies








12 Renal Dialysis



13B



13C Meal Benefit


13C


benefit provides?












14C






M4P2 M4P2

Arizona Arizona

4185-Viad

4123-Lacera


H0354-804 H0354-805

HMO HMO

Confirmed Confirmed


year


year

$12 $12

$12 $12

$12 $12

$12 $12

$12 $12

$12 $12

In PCP office - $0


In PCP office - $0


$12 $12

$12 $12

$12 $12

$0 $0

$0 $0






CMG - $100

ASC/HospOP - $150




$12 $12

$0 $0


All else-$12

$12


All else-$12

$12

$12 $12

$12 $12


$0 $0

$0 $0


$0 $0

$0 $0

$0 $0

$0 $0

$0 $0

$12 $12










$0 $0

Not covered $0

Not covered $0

Not covered $0


$0 $0



$0 $0




of 20



2017BENEFIT OPTION

Region

Plan Name

Contract and ID #

Plan Type


PBP Category



14C


Reconciliation








15


Office Injectables

15





16A


Dental


16B


Sharing


16B


Sharing

16B

Comp Dental:


Sharing

16B



Sharing

16B






17A


Exams



17B


Coverage







Section Rx Part D









M4P2 M4P2

Arizona Arizona

4185-Viad

4123-Lacera


H0354-804 H0354-805

HMO HMO

Confirmed Confirmed


Not covered $0






$0 $0

$0 $0

$0 $0






SVN Meds - $0







SVN Meds - $0


Yes Yes











$12 $12



services

$12



$0 $0



every year





every year




$12 $12

$0 $0

$0 $0


Unlimited Unlimited


OPTION P2



No No

No No

5 5

4 4

$0 $0


of 20



2017BENEFIT OPTION

Region

Plan Name

Contract and ID #

Plan Type


PBP Category



Section Rx


Supply

Section Rx


Month Supply

Section Rx


Month Supply

Section Rx


Month Supply

M4P2 M4P2

Arizona Arizona

4185-Viad

4123-Lacera


H0354-804 H0354-805

HMO HMO

Confirmed Confirmed


Tier 2: Generic



Tier 5: Specialty


Tier 2: Generic



Tier 5: Specialty


Tier 2: Generic


Brand


Preferred Brand



Tier 2: Generic


Brand


Preferred Brand


Tier 1: $0.00

Tier 2: $0.33

Tier 3: $1.50

Tier 4: $3.17

Tier 1: $0.00

Tier 2: $0.33

Tier 3: $1.50

Tier 4: $3.17

Tier 1: $0

Tier 2: $10

Tier 3: $45

Tier 4: $95

Tier 5: 33%

Tier 1: $0

Tier 2: $10

Tier 3: $45

Tier 4: $95

Tier 5: 33%

Tier 1: $0

Tier 2: $20

Tier 3: $90

Tier 4: $190


Tier 1: $0

Tier 2: $20

Tier 3: $90

Tier 4: $190


Tier 1: $0

Tier 2: $30

Tier 3: $135

Tier 4: $285


Tier 1: $0

Tier 2: $30

Tier 3: $135

Tier 4: $285


of 20



2017BENEFIT OPTION

Region

Plan Name

Contract and ID #

Plan Type


PBP Category

Section Rx


supply

Section Rx


Month Supply

Section Rx


Month Supply

Section Rx


Month Supply


Section Rx


Daily Supply

Section Rx


One Month Supply

Section Rx


Three Month Supply










M4P2 M4P2

Arizona Arizona

4185-Viad

4123-Lacera


H0354-804 H0354-805

HMO HMO

Confirmed Confirmed

Tier 1: $

Tier 2: $

Tier 3: $

Tier 4: $

Tier 1: $

Tier 2: $

Tier 3: $

Tier 4: $

Tier 1: $

Tier 2: $

Tier 3: $

Tier 4: $

Tier 1: $

Tier 2: $

Tier 3: $

Tier 4: $

Tier 1: $

Tier 2: $

Tier 3: $

Tier 4: $

Tier 1: $

Tier 2: $

Tier 3: $

Tier 4: $

Tier 1: $

Tier 2: $

Tier 3: $

Tier 4: $

Tier 1: $

Tier 2: $

Tier 3: $

Tier 4: $









Tier 1: $0.00

Tier 2: $0.33

Tier 3: $1.50

Tier 4: $3.17

Tier 1: $0.00

Tier 2: $0.33

Tier 3: $1.50

Tier 4: $3.17

Tier 1: $0

Tier 2: $10

Tier 3: $45

Tier 4: $95

Tier 5: 33%

Tier 1: $0

Tier 2: $10

Tier 3: $45

Tier 4: $95

Tier 5: 33%

Tier 1: $0

Tier 2: $30

Tier 3: $135

Tier 4: $285


Tier 1: $0

Tier 2: $30

Tier 3: $135

Tier 4: $285








Tier 1: $0

Tier 2: $10

Tier 3: $45

Tier 4: $95

Tier 5: 33%

Tier 1: $0

Tier 2: $10

Tier 3: $45

Tier 4: $95

Tier 5: 33%


Tier 1: $0.00

Tier 2: $0.32

Tier 3: $1.45

Tier 4: $3.06

Tier 1: $0.00

Tier 2: $0.32

Tier 3: $1.45

Tier 4: $3.06

Tier 1: $0

Tier 2: $10

Tier 3: $45

Tier 4: $95

Tier 5: 33%

Tier 1: $0

Tier 2: $10

Tier 3: $45

Tier 4: $95

Tier 5: 33%




$4950


$4850

All Tiers All Tiers

Preventive services covered under Medicare will have a zero office visit cost share if the only

service being performed during the office visit is the preventive service. If the preventive service is

performed in conjunction with other services in the same office visit, then the applicable office visit

copayment may be charged. Also, the office visit copay may be charged for these services that

are diagnostic in nature (if applicable).

Copays/Coinsurance incurred by customers for covered benefits shown on this chart apply to the out-

of-pocket maximum. Cost incurred for non-covered services are not covered. For example, if a

customer exhausts the SNF days and continues to remain in the facility, costs incurred by the member

for non-covered days in the SNF do not apply to the OOP maximum. Also, Part D copays apply to the

Part D out-of-pocket limit (TrOOP).

Separate Office Visit will apply if diagnostic services provided in conjunction with an office visit. Office

visit copay will not apply if no office visit was incurred.

Copyright© 2017 Cigna HealthCare of Arizona, Inc. all rights reserved. This material may not be

reproduced, in whole or in part, without the expressed written permission of the owner, Cigna

HealthCare of Arizona, Inc. Use and distribution is limited solely to authorized personnel.

of 20

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