AARP Medicare Advantage Choice Plan 2 H2228-094 (PPO) Plan Details

Arizona Counties Served

Plan Details and Plan Costs

AARP Medicare Advantage Choice Plan 2 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered in Arizona by AARP. The plan ID is H2228:094-0.

Monthly Premium: $0.00
Plan Deductible: $0
Out of Pocket Spending Max: $6200

Primary Care Doctor Visit

In Network: Copayment for Primary Care Office Visit $0.00

Out of Network: Copayment for Medicare Covered Primary Care Office Visit $35.00

Specialist Doctor Visit

In Network:

$35 Copayment for Physician Specialist Office Visit
Prior Authorization Required for Doctor Specialty Visit
Out of Network: Copayment for Medicare Covered Physician Specialist Office Visit $70.00

Inpatient Hospital Care

In Network:

$300 per day for days 1 to 6
$0.00 per day for days 7 to 90
Prior Authorization Required for Acute Hospital Services
Out of Network: Coinsurance for Acute Hospital Services per Stay 40%

Urgent Care

Copayment for Urgent Care $30 to $40.00

Section B - General 4b Note - NOTE ON COST SHARING FOR URGENT CARE: Minimum copay for Contracted Urgent Care Center. Maximum copay for other Urgent Care

Copayment for Worldwide Urgent Coverage: $0.00

Emergency Room (ER) Visits

In Network:

Copayment for Emergency Care: $90.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours.
Worldwide Coverage: Copayment for Worldwide Emergency Coverage $0.00
Copayment for Worldwide Emergency Transportation $0.00

Ambulance Transportation

In Network:

Ground Ambulance: $250 copayment
Air Ambulance: $250 copayment
Section B - General 10a Note - NOTE ON AUTHORIZATION: Authorization is required for Non-emergency Medicare-covered ambulance ground and air transportation. Emergency Ambulance does not require authorization.
Please see Evidence of Coverage for Prior Authorization rules

Additional Covered Health Care Services and Medical Supplies

AARP Medicare Advantage Choice Plan 2 (PPO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Home Health Care

In Network: $0.00 Copay

Prior Authorization Required for Home Health Services
Referral Required for Home Health Services
Out of Network: Coinsurance for Medicare Covered Home Health 50%

Skilled Nursing Facility (SNF) Care

In Network:

$0.00 per day for days 1 to 20
$184.00 per day for days 21 to 54
$0.00 per day for days 55 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Out of Network: $225.00 per day for days 1 to 45
$0.00 per day for days 46 to 100

Medical Diagnostic Tests, Labs and Radiology Services

Outpatient Diagnostic Procedures, Tests and Lab Services:

Copayment for Medicare-covered Diagnostic Procedures/Tests: $30
Copayment for Medicare-covered Lab Services: $0.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diagnostic and Therapeutic Radiology Services:

Copayment for Medicare-covered Diagnostic Radiological Services: $0 to $125
Copayment for Medicare-covered Therapeutic Radiological Services: $60
Copayment for Medicare-covered X-Ray Services $15.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Referral Required for Outpatient Diag/Therapeutic Rad Services

Diabetes Supplies, Training, Nutrition Therapy and Monitoring

In-Network:

Copayment for Medicare-covered Diabetic Supplies $0.00
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%
Prior Authorization Required for Diabetic Supplies and Services
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)

Durable Medical Equipment (DME)

In Network:

Coinsurance for Medicare-covered Durable Medical Equipment 20%
Out of Network: Coinsurance for Medicare Covered Durable Medical Equipment 50%

Chiropractic Services

In Network:

Copayment for Medicare-covered Chiropractic Services: $20.00
Prior Authorization Required for Chiropractic Services

Out of Network:

Copayment for Medicare Covered Chiropractic Services $70.00

Mental Health Inpatient Care

In Network:

$335 per day for days 1 to 5
$0.00 per day for days 6 to 90
Prior Authorization Required for Psychiatric Hospital Services
Out of Network: Coinsurance for Psychiatric Hospital Services per Stay 40%

Mental Health Outpatient Care

In Network:

Copayment for Medicare-covered Individual Sessions: $25
Copayment for Medicare-covered Group Sessions: $15
Prior Authorization Required for Outpatient Mental Health Services
Out of Network: Copayment for Medicare Covered Individual Sessions $30.00 to $40.00
Copayment for Medicare Covered Group Sessions $30.00 to $40.00

Outpatient Substance Abuse Care

In Network:

Copayment for Medicare-covered Individual Sessions: $25
Copayment for Medicare-covered Group Sessions: $15
Prior Authorization Required for Outpatient Substance Abuse Services

Podiatry Services

In Network:

In Network: Copayment for Medicare-Covered Podiatry Services $45.00
Copayment for Routine Foot Care $45.00
Maximum 6 visits every year
Prior Authorization Required for Podiatry Services

Dental Benefits

The following dental services are covered from in-network providers.

Preventive Dental Care

Medicare-covered benefits:

Oral Exams: $0.00 Copayment
Maximum 2 visits every year
Teeth Cleaning: $0.00 Copayment
Maximum 3 visits every year
Fluoride Treatment: $0.00 Copayment
Maximum 2 visits every year
Dental X-Rays: $0.00 Copayment
Maximum 1 visit (Please see Evidence of Coverage for details)
Maximum Plan Benefit of $500.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined

Comprehensive Dental Care

Medicare-Covered Benefits:

Coinsurance for Medicare-covered Benefits 20%
Copayment for Diagnostic Services $0.00
Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Restorative Services $0.00
Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $0.00
Maximum Plan Benefit of $500.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined
Prior Authorization Required for Comprehensive Dental

Vision Benefits

The following vision services are covered from in-network providers.

Eye Exams

Medicare-Covered Benefits:

Copayment for Medicare Covered Benefits $0.00
Copayment for Routine Eye Exams $0.00
Maximum 1 Routine Eye Exam every year
Prior Authorization Required for Eye Exams

Eyewear

Medicare-Covered Benefits:

Medicare-Covered Benefits: $0.00 Copayment
Copayment for Contact Lenses $0.00
Copayment for Eyeglasses (lenses and frames) $0.00 Copayment
Maximum 1 Pair every two year
Maximum Plan Benefit: $100.00 every two years for all Non-Medicare covered eyewear

Hearing Benefits

The following vision services are covered from in-network providers.

Hearing Exams

Medicare-Covered Benefits:

Copayment for Medicare Covered Benefits $0.00
Copayment for Routine Hearing Exams $0.00
Maximum 1 visit every year
Prior Authorization Required for Hearing Exams

Preventive Services and Health/Wellness Education Programs

The following preventive services and wellness education programs are covered from in-network providers with $0.00 Copayment required.

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
Tobacco use cessation

Shots:

Flu shots
Hepatitis B shots
Pneumococcal shots

Prescription Drug Costs and Coverage

The AARP Medicare Advantage Choice Plan 2 (PPO) plan offers the following prescription drug coverage in Arizona, with an annual drug deductible of $295 per year.

Preferred Generic Drugs

Preferred Mail Order Cost Sharing (90 Day Supply) $0.00
Standard Retail Cost Sharing (30 Day Supply) $2.00
Standard Mail Order Cost Sharing (90 Day Supply) $6.00

Generic Drugs

Preferred Mail Order Cost Sharing (90 Day Supply) $0.00
Standard Retail Cost Sharing (30 Day Supply) $12.00
Standard Mail Order Cost Sharing (90 Day Supply) $36.00

Preferred Brand Name Drugs

Preferred Mail Order Cost Sharing (90 Day Supply) $125.00
Standard Retail Cost Sharing (30 Day Supply) $45.00
Standard Mail Order Cost Sharing (90 Day Supply) $135.00

Non-Preferred Drugs

[referred Mail Order Cost Sharing (90 Day Supply) $275.00
Standard Retail Cost Sharing (30 Day Supply) $95.00
Standard Mail Order Cost Sharing (90 Day Supply) $285.00

Specialty Tier Drugs

Standard Retail Cost Sharing (30 Day Supply) 27%