Cigna-HealthSpring CarePlan of Illinois H6751-001
2017 Plan Details


 
The chart below is a brief overview of Cigna-HealthSpring's CarePlan of Illinois. If you would like to view the plan in greater detail download a copy of the 2017 Summary of Benefits.3
 
This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more information contact the plan or read the 2017 Member Handbook/Evidence of Coverage.
 
Benefits, List of Covered Drugs, pharmacy and provider networks may change from time to time throughout the year and on January 1 of each year.
 
If you speak a language other than English, language assistance services, free of charge, are available to you. Call (866) 487-4331 (TTY 711) 8:00am to 8:00pm local time. Translations of this alternate language tagline can be found here.
 

 
 
 
CIGNA-HEALTHSPRING 2017 BENEFITS
Premiums and Other
Important Information
1,2
 
Monthly Plan Premium: $0.00
 
Drug Coverage: YES
 
Diagnostic procedures and tests: $0.00.
Lab tests, such as blood work; X-rays or other pictures, such as CAT scans; Screening tests, such as tests to check for cancer. Authorization rules may apply. A referral may be required. No prior authorization needed for X-ray.
 
Doctor and Hospital Choice
 
You must use the providers in Cigna-HealthSpring CarePlan of Illinois’ network. If you need urgent or emergency care or out-of-area dialysis services, you can use providers outside of Cigna-HealthSpring CarePlan of Illinois' plan.
 
To find out if your doctors are in the plan’s network, call Customer Service or read Cigna-HealthSpring CarePlan of Illinois’ Provider and Pharmacy Directory.
 
Most services will be provided by our network providers. If you need a service that cannot be provided within our network, Cigna- HealthSpring CarePlan of Illinois will pay for the cost of an out-of-network provider.
 
Inpatient Hospital Care
 
Copay: $0.00
 
Authorization rules may apply. A referral is required. Our plan covers an unlimited number of days for an inpatient hospital stay.
 
You must go to an in-network hospital.
 
You must go to a network hospital
 
Doctor Office Visits
 
Wellness Visit: $0.00
 
Preventative Care (such as flu shots): $0.00
 
Primary Care:$0.00
 
Specialist Care: $0.00 – A referral is required.
 
Emergency Care
 
Copay: $0.00
 
Prior Authorization is NOT required.
 
You may go to any emergency room if you reasonably believe you need emergency care.
 
$50,000 (US currency) combined limit per year for emergency and urgent care services provided outside the U.S. and its territories.
 
Ambulance Services
 

Copay: $0.00

 
Authorization rules may apply for non-emergency Medicare services.
 
Urgently Needed Care
 
Copay: $0.00
 
This is NOT emergency care.
 
Prior Authorization is NOT required.
 
You may go to any urgent care center if you reasonably believe you need urgent care.
 
$50,000 (US currency) combined limit per year for emergency and urgent care services provided outside the U.S. and its territories.
 
Dental Services
 
Copay: $0.00
 
Preventative dental services:
  • One (1) Cleaning every six months

  • One (1) Oral exam every six months

  • One (1) Bitewing X-ray every year

  • One (1) Full mouth & panoramic X-ray every 36 months
 
For additional dental benefits, please see your Member Handbook.
 
Hearing Services
 
Copay: $0.00
 
One (1) routine hearing exam every year. A referral is required.
 
One (1) hearing aid every 3 years. A referral is required.
 
Vision Services
 
Copay: $0.00
 
One (1) routine eye exam a year and as medically necessary.
 
One (1) eyeglasses (frames and lenses) OR contact lenses up to one (1) every two years.
 
 
 
 
 
PRESCRIPTION DRUGS4
Generic and Brand Drugs
 
Copay: $0.00.
 
There may be limitations on the types of drugs covered. Please see Cigna-HealthSpring CarePlan of Illinois’ List of Covered Drugs (Drug List) for more information.
 
Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.
 
Retail Pharmacy
You can get drugs the following way(s):
  • One-month (30-day) supply

  • Two-month (60-day) supply

  • Three-month (90-day) supply
 
Mail Order Pharmacy
You can get drugs the following way(s):
  • One-month (30-day) supply

  • Three-month (90-day) supply
 
Not all drugs are available at this extended day supply.
 
Please contact the plan for more information.
 
See Summary of Benefits for further details.
 
Part D and non-Part D
Drug List
Updated June, 2017
 
 
There may be limitations on the types of drugs covered. Please see Cigna-HealthSpring CarePlan of Illinois ’ List of Covered Drugs for more information.
 
The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you.
 
Medicare Part B
Prescription Drugs
 
Copay: $0.00.
 
Authorization rules may apply.
 
Part B drugs include drugs given by your doctor in his or her office, some oral cancer drugs, and some drugs used with certain medical equipment. Read the Member Handbook for more information on these drugs.
 
Over the Counter Drugs
 
$10 monthly allowance. Members are required to contact OTC benefit vendor to access this benefit. Unused balance can roll forward each month, but must be used by December 31st. Balance does not carry over year to year. Limited to one order per member per month.
 
See Summary of Benefits for further details.
 
 
 
 
 
IMPORTANT DOCUMENTS
Summary of Benefits3
 
 
 
Member Handbook3
 
(Evidence of
Coverage - EOC)
 
 
 
 
Annual Notice
of Changes
 
 
 
Service Area Listings
 
The service area for this plan includes: Cook, DuPage, Kane, Lake and Will Counties, IL. You must live in one of these areas to join the plan.
 
 
1For full-dual benefit members the State will continue to pay your Medicare Part B Premium.
 
2The copay covers extra services and drugs not covered by Medicare. Copays for prescription drugs may vary based on the level of Extra Help you receive. Please contact the plan for more details.
 
3You can get this information for free in other languages. Call 1-866-487-4331 (TTY: 7-1-1), 7 days a week, 8 a.m. to 8 p.m. Central Time. The call is free. Usted puede obtener gratuitamente esta información en otros idiomas. Llame al 1-866-487-4331 (TTY: 7-1-1), 7 días de la semana, de 8 a.m. a 8 p.m. hora del Centro. La llamada es gratuita.
 
Materials are also published in alternate formats (examples: large print, Braille, audio CD). Call 1-866-487-4331; TTY 711 for more information.
 
4Eligible beneficiaries must use network pharmacies to access their prescription drug benefit except under non-routine circumstances, and quantity limitations and restrictions may apply.
 
Limitations and restrictions may apply. For more information, call Cigna-HealthSpring CarePlan of Illinois Customer Service or read the Cigna-HealthSpring CarePlan of Illinois 2017 Member Handbook/Evidence of Coverage (EOC).
 

 
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