Aetna Medicare Advantra Gold (PPO)
Aetna Medicare Advantra Gold (PPO) H1608-026 Plan Details
Aetna Medicare Advantra Gold (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H1608-026.
$55.00
Monthly Premium
Aetna Medicare Advantra Gold (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H1608-026.
Aetna Medicare Advantra Gold (PPO) H1608-026 Plan Details
Aetna Medicare Advantra Gold (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H1608-026.
$55.00
Monthly Premium
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $6001 Out-of-Network: N/A |
| Initial Coverage Limit | $4660 |
| Catastrophic Coverage Limit | $7,400 |
| Primary Care Doctor Visit | $10 in-network / $15 out-of-network |
| Specialty Doctor Visit | $40 in-network / 20% out-of-network |
| Inpatient Hospital Care | $400 per stay in-network / $450 per stay out-of-network |
| Urgent Care | Copayment for Urgent Care $50.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $95.00 |
| Emergency Room Visit | $95 If you are admitted to the hospital within 24 hours your cost share may be waived, for more information see the Evidence of Coverage |
| Ambulance Transportation | $255 in-network / $255 out-of-network |
Health Care Services and Medical Supplies
Aetna Medicare Advantra Gold (PPO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
| Coverage | Cost |
|---|---|
| Chiropractic Services | In-Network: Copayment for Medicare-covered Chiropractic Services $20.00 Prior Authorization Required for Chiropractic Services Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Chiropractic Services 20% |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | 0% - 20% Higher cost-share applies to non-OneTouch/LifeScan diabetic supplies. |
| Durable Medical Eqipment (DME) | 20% in-network / 30% out-of-network |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | Lab Services: Lab Services: $5 in-network/ $15 out-of-network, for more information see Evidence of Coverage Diagnostic Procedures: Diagnostic Procedures/Tests: $10 in-network/ 20% out-of-network, for more information see Evidence of Coverage Imaging: Xray: $25 in-network / CT Scans: $10 for services provided by your primary care physician in their office in-network; $265 for services performed by a provider other than your primary care physician in-network / Diagnostic Radiology other than CT Scans: $10 for services provided by your primary care physician in their office in-network; $265 for services performed by a provider other than your primary care physician in-network / Diagnostic Radiology Mammogram: $0 in-network / 20% out-of-network, for more information see Evidence of Coverage |
| Home Health Care | $0 in-network / $0 out-of-network |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital Services per Stay $1590.00 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required Out-of-Network: Coinsurance for Psychiatric Hospital Services per Stay 45% |
| Mental Health Outpatient Care | Mental Health: Group Sessions: $40 in-network/ Individual Sessions: $40 in-network/ 45% out-of-network, for more information see Evidence of Coverage Psychiatric Services: Group Sessions: $40 in-network/ Individual Sessions: $40 in-network/ 45% out-of-network, for more information see Evidence of Coverage |
| Outpatient Services / Surgery | Ambulatory Surgical Center: $250 in-network / ASC Screening Colonoscopy Polyp Removal and Post-FIT: $0 in-network / 20% out-of-network, for more information see Evidence of Coverage |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $45.00 Copayment for Medicare-covered Group Sessions $45.00 Prior Authorization Required for Outpatient Substance Abuse Services Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Individual or Group Sessions 45% |
| Over-the-counter (OTC) Items | $75 quarterly OTC allowance, for more information see Evidence of Coverage |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $40.00 Copayment for Routine Foot Care $40.00
Out-of-Network: Coinsurance for Medicare Covered Podiatry Services 20% Coinsurance for Non-Medicare Covered Podiatry Services 20% |
| Skilled Nursing Facility Care | $0 per day, days 1-20 $196 per day, days 21-100 In-Network: 40% per stay Out-of-Network: for more information see Evidence of Coverage |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | $2,000 maximum benefit for preventive and comprehensive dental services combined - see Evidence of Coverage. |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | $150 every year, see the Evidence of Coverage |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | $1,250 per ear every year, for more information see the Evidence of Coverage |
Preventive Services and Health/Wellness Education Programs
The following services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Preventive Services and Health/Wellness Education Programs | $0 copay for all preventive services covered under Original Medicare at zero cost sharing |
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