AARP Medicare Advantage Plan H5253-036 (HMO) Plan Details

Arizona Counties Served

Yavapai County

Plan Details and Plan Costs

AARP Medicare Advantage (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered in Arizona by AARP. The plan ID is H0271:008-0.

• Monthly Premium: $27.20
• Plan Deductible: $0
• Out of Pocket Spending Max: $7500

Primary Care Doctor Visit

In Network: Copayment for Primary Care Office Visit $10.00

Out of Network: 30% Coinsurance

Specialist Doctor Visit

In Network:

• $25 Copayment for Physician Specialist Office Visit
• Prior Authorization Required for Doctor Specialty Visit
• Referral Required for Doctor Specialty Visit

Inpatient Hospital Care

In Network:

• $225 per day for days 1 to 7
• $0.00 per day for days 8 to 90
• Prior Authorization Required for Acute Hospital Services
• Referral Required for Acute Hospital Services

Urgent Care

Copayment $40.00

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 (HMO) 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

Skilled Nursing Facility (SNF) Care

In Network:

• $0.00 per day for days 1 to 20
• $184.00 per day for days 21 to 50
• $0.00 per day for days 36 to 100
• Prior Authorization Required for Skilled Nursing Facility Services
• Referral Required for Skilled Nursing Facility Services

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

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%
• Prior Authorization Required for Durable Medical Equipment

Chiropractic Services

In Network:

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

Mental Health Inpatient Care

In Network:

• $225 per day for days 1 to 7
• $0.00 per day for days 8 to 90
• Prior Authorization Required for Psychiatric Hospital Services
• Referral Required for Psychiatric Hospital Services

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
• Referral Required for Outpatient Mental Health Services

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
• Referral Required for Outpatient Substance Abuse Services

Podiatry Services

In Network:

• In Prosthetics/Medical Supplies:
• Coinsurance for Medicare-covered Prosthetic Devices 20%
• Coinsurance for Medicare-covered Medical Supplies 20%
• Prior Authorization Required for Prosthetics/Medical Supplies

Over-the-Counter (OTC) Items

• $0.00 Copayment
• Maximum Plan Benefit of $40.00 every three months
• Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit

Dental Benefits

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

Comprehensive Dental Care

Medicare-Covered Benefits:

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

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: $500.00 every year for Preventive and Non-Medicare Covered Comprehensive combined

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:

• Copayment for Medicare-Covered Benefits $0.00
• Copayment for Contact Lenses $0.00
• Copayment for Eyeglasses (lenses and frames) $0.00
• Maximum 1 Pair every two years
• Maximum Plan Benefit of $200.00 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

Hearing Aids

• Copayment for Hearing Aids $375.00 to $2075.00
• Maximum 2 Hearing Aids every two years
• Prior Authorization Required for Hearing Aids
• Section B - General 18b Note - NOTE ON COST SHARING: Copays will range from a minimum copay of $375 to a maximum of $2,075 based on features and style. NOTE ON COMBINED COVERAGE FOR HEARING AID BENEFIT: Member may purchase a total of two hearing aids every two years.

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 (HMO) plan offers the following prescription drug coverage in Arizona, with an annual drug deductible of $0 per year.

Preferred Generic Drugs

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

Generic Drugs

• Preferred Mail Order Cost Sharing (90 Day Supply) $0.00
• Standard Retail Cost Sharing (30 Day Supply) $8.00
• Standard Mail Order Cost Sharing (90 Day Supply) $24.00

Preferred Brand Name Drugs

• Preferred Mail Order Cost Sharing (90 Day Supply) $125
• Standard Retail Cost Sharing (30 Day Supply) $45.00
• Standard Mail Order Cost Sharing (90 Day Supply) $135.00

Non-Preferred Drugs

• Preferred 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) 33%