AARP Walgreens Plan 3 H228-097 (PPO) Plan Details

In this article...
  • Learn more about HumanaChoice R7220-002 (Regional PPO) R7220:002-0 Plan Details, including how much you can expect to pay for coinsurance, deductibles, premiums and copays for various services covered by the plan.

Arizona Counties Served

Maricopa County

Plan Details and Plan Costs

AARP Medicare Advantage Walgreens Plan 3 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered in Arizona by AARP. The plan ID is H2228:097-0.

  • 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: $265 copayment
  • Air Ambulance: 20% Coinsurance

Additional Covered Health Care Services and Medical Supplies

AARP Medicare Advantage Walgreens Plan 3 (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: $35.00
  • Copayment for Routine Foot Care: $35.00
  • 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

Hearing Aids

Copayment for Hearing Aids $699.00 to $999.00

  • 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 Walgreens Plan 3 (PPO) plan offers the following prescription drug coverage in Arizona, with an annual drug deductible of $195 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) 29%
  • Standard Retail Cost Sharing (30 Day Supply) 29%
Read More
Smiling couple outdoors with sun in the background
How do Medigap plans and Medicare Advantage plans differ? How can you decide which type of plan is ...
Happy Couple Visiting With Friends
How much does Medicare cost? Are there affordable options available to help seniors with out-of-pocket ...
Man uses laptop computer at home in his kitchen
Medicare.gov is an important resource for Medicare enrollees. Learn about some of the features the ...