Aetna Medicare Advantra Premier Plus (PPO)
Aetna Medicare Advantra Premier Plus (PPO) H5522-014 Plan Details
Aetna Medicare Advantra Premier Plus (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5522-014
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$59.00
Monthly Premium
Aetna Medicare Advantra Premier Plus (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5522-014
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
Aetna Medicare Advantra Premier Plus (PPO) H5522-014 Plan Details
Aetna Medicare Advantra Premier Plus (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5522-014
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
$59.00
Monthly Premium
Pennsylvania Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $5900 Out-of-Network: N/A |
| Initial Coverage Limit | $5030 |
| Catastrophic Coverage Limit | $8,000 |
| Primary Care Doctor Visit | $5 in-network | 10% out-of-network |
| Specialty Doctor Visit | $45 in-network | 10% out-of-network |
| Inpatient Hospital Care | $475 per stay in-network | 20% per stay out-of-network |
| Urgent Care | Copayment for Urgent Care $50.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $100.00 |
| Emergency Room Visit | $100 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 Premier Plus (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 $15.00 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) | 0% - 20% for each Medicare-covered durable medical equipment item | 0% for continuous glucose meters | 20% for all other Medicare-covered DME items | 20% out-of-network |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | Lab Services: Lab Services: $0 in-network| 20% out-of-network, for more information see Evidence of Coverage Diagnostic Procedures: Diagnostic Procedures/Tests: $5 in-network| 20% out-of-network, for more information see Evidence of Coverage Imaging: Xray: $35 in-network | CT Scans: $5 for services provided by your primary care physician in their office in-network; $275 for services performed by a provider other than your primary care physician in-network | Diagnostic Radiology other than CT Scans: $5 for services provided by your primary care physician in their office in-network; $275 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: $350.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required Out-of-Network: Coinsurance for Psychiatric Hospital Services per Stay 20% |
| 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: $0 in network for preventive and diagnostic colonoscopy | $245 All other in network ASC services | 10% out-of-network, for more information see Evidence of Coverage |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $40.00 Copayment for Medicare-covered Group Sessions $40.00 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 | In Network: |Over-the-counter (OTC) items:|$120 quarterly amount (allowance) to purchase approved OTC health and wellness products like first aid supplies, cold and allergy medicine, pain relievers and more. Approved items can be purchased online, in store, or by phone. |Be sure to use the full benefit amount quarterly, because any unused amount will not rollover.|Nicotine Replacement Therapy(NRT) offered as a Part C OTC benefit, for more information see Evidence of Coverage |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $45.00 Copayment for Routine Foot Care $45.00
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 $203 per day, days 21-100 in-network| 20% 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 | In Network Dental Coverage|For covered services: ADA recognized dental services are covered excluding only cosmetic services, those considered medical in nature, and administrative changes.|Preventive dental services: |Oral exams: $0 copay |Cleanings: $0 copay |Fluoride treatment: $0 copay |Bitewing x-rays: $0 copay |Comprehensive dental services:|Non-routine services: $0 copay |Diagnostic services: $0 copay |Restorative services: $0 copay |Endodontics: $0 copay |Periodontics: $0 copay |Extractions: $0 copay |Prosthodontics and maxillofacial services: $0 copay |Out Of Network Dental Coverage|Preventive dental services:| 20% coinsurance |Comprehensive dental services:| 20% coinsurance |$3,000 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 | In-Network:|Eye Exams:|Copayment for Medicare Covered Benefits $0-$45|Copayment for Routine Eye Exams $0 |(Maximum one exam every year)|Eyewear:|Copayment for Medicare Covered Benefits $0|Copayment for Contacts $0|Copayment for Eyeglasses $0|Copayment for Eyeglass Frames $0|Copayment for Eyeglass Lenses $0|Copayment for Upgrades $0|Out-of-Network:|Eye Exams:|Coinsurance for Medicare-Covered Benefits 20%|Coinsurance for Routine Eye Exams 20%|Eyewear:|Coinsurance for Medicare-Covered Benefits 20%|Copayment for Non-Medicare covered Benefits $0|Maximum Plan Allowance for all Non-Medicare covered Eyewear $500 every year. See the Evidence of Coverage |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network:|Hearing Exams:|Copayment for Medicare Covered Benefits $45|Copayment for Routine hearing Exams $0|(Maximum one exam every year)|Copayment for Fitting/Evaluation for Hearing Aid $0|(Maximum one hearing aid fitting/evaluation every year)|Hearing Aids:|Copayment for Hearing Aids $0|(Maximum two hearing aids every year) |Out-of-Network:|Coinsurance for Medicare Covered Hearing Exams 20%|Coinsurance for Non-Medicare Covered Hearing Exams 20% |Member must purchase hearing aids through NationsHearing|$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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