AARP Walgreens Plan 2 H228-096 (PPO) Plan Details

Arizona Counties Served

Plan Details and Plan Costs

AARP Medicare Advantage Walgreens Plan 2 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered in Arizona by AARP. The plan ID is H2228:096-0.

Monthly Premium: $25
Plan Deductible: $0.00
Out of Pocket Spending Max: $4000

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

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:

$250.00 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:

40% Coinsurance for Acute Hospital Services per Stay

Urgent Care

Copayment for Urgent Care $30.00 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: $90.00

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

Out of Network:

Ground Ambulance: $250 copayment
Air Ambulance: $250 copayment

Additional Covered Health Care Services and Medical Supplies

AARP Medicare Advantage Walgreens 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

Out of Network: 50% Coinsurance

Skilled Nursing Facility (SNF) Care

In Network:

$0.00 per day for days 1 to 20
$184.00 per day for days 21 to 42
$0.00 per day for days 43 to 100
Prior Authorization Required for Skilled Nursing Facility Services

Out of Network:

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

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:

$250.00 per day for days 1 to 6
$0.00 per day for days 7 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:

Coinsurance for Medicare Covered Individual Sessions: $30-40
Coinsurance for Medicare Covered Group Sessions: $30-40

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:

Copayment for Medicare-Covered Podiatry Services: $30.00
Copayment for Routine Foot Care: $30.00
Maximum 6 visits every year
Prior Authorization Required for Podiatry Services

Dental Benefits

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

Preventative Dental Care

Medicare-Covered Benefits:

Copayment for Oral Exams $0.00
Maximum 2 visits every year
Teeth Cleaning: Copayment for Prophylaxis (Cleaning) $0
Maximum 3 visits every year
Copayment for Fluoride Treatment $0.00
Maximum 2 visits every year
Dental X-Rays: Copayment for Dental X-Rays $0 (Maximum 1 visit per year)
Maximum Plan Benefit of $1000.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined

Comprehensive Dental Care

Coinsurance for Medicare-covered Benefits 20%

Copayment for Non-routine Services $0.00
Copayment for Diagnostic Services $0.00
Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Restorative Services $0.00
Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Endodontics $0.00
Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Periodontics $0.00
Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Extractions $0.00
Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $0.00
Maximum 1 visit (Please see Evidence of Coverage for details)
Maximum Plan Benefit of $1000.00 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:

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 for in and out of network services combined

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 Walgreens Plan 2 (PPO) plan offers the following prescription drug coverage in Arizona, with an annual drug deductible of $275 per year.

Preferred Generic Drugs

Preferred Retail Cost Sharing (30 Day Supply) $0.00
Preferred Mail Order Cost Sharing (90 Day Supply) $0.00
Standard Retail Cost Sharing (30 Day Supply) $10.00
Standard Mail Order Cost Sharing (90 Day Supply) $30.00

Generic Drugs

Preferred Retail Cost Sharing (30 Day Supply) $0.00
Preferred Mail Order Cost Sharing (90 Day Supply) $0.00
Standard Retail Cost Sharing (30 Day Supply) $20.00
Standard Mail Order Cost Sharing (90 Day Supply) $60.00

Preferred Brand Name Drugs

Preferred Retail Cost Sharing (30 Day Supply) $47.00
Preferred Mail Order Cost Sharing (90 Day Supply) $131.00
Standard Retail Cost Sharing (30 Day Supply) $47.00
Standard Mail Order Cost Sharing (90 Day Supply) $141.00

Non-Preferred Drugs

Preferred Retail Cost Sharing (30 Day Supply) $100.00
Preferred Mail Order Cost Sharing (90 Day Supply) $290.00
Standard Retail Cost Sharing (30 Day Supply) $100.00
Standard Mail Order Cost Sharing (90 Day Supply) $300.00

Specialty Tier Drugs

Preferred Retail Cost Sharing (30 Day Supply) 28%
Standard Retail Cost Sharing (30 Day Supply) 28%