Aetna Medicare Choice Plan (PPO)

Aetna Inc.
Aetna Medicare Choice Plan (PPO) H3288-008 Plan Details
3.5 out of 5 stars

Aetna Medicare Choice Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H3288-008.

$0.00
Monthly Premium

Aetna Medicare Choice Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H3288-008.

Aetna Inc.
Aetna Medicare Choice Plan (PPO) H3288-008 Plan Details
3.5 out of 5 stars

Aetna Medicare Choice Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H3288-008.

$0.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $250
Out of Pocket Max In-Network: $6700
Out-of-Network: N/A
Initial Coverage Limit $4660
Catastrophic Coverage Limit $7,400
Primary Care Doctor Visit
$0 in-network / 50% out-of-network
Specialty Doctor Visit
$50 in-network / 50% out-of-network
Inpatient Hospital Care
$315 per day, days 1-7; $0 per day, days 8-90 in-network / 50% per stay out-of-network
Urgent Care
Copayment for Urgent Care $0.00 to $60.00

Minimum copayment applies to urgently needed services provided in a PCP office. Maximum copayment applies to urgently needed services provided in an urgent care facility or location other than PCP.

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $95.00
Emergency Room Visit
$95 If you are admitted to the hospital within 0 hours your cost share may be waived, for more information see the Evidence of Coverage
Ambulance Transportation
$280 in-network / $280 out-of-network

Health Care Services and Medical Supplies

Aetna Medicare Choice Plan (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 50%
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 / 45% out-of-network
Diagnostic Tests, Lab and Radiology Services, and X-Rays
Lab Services: Lab Services: $0 in-network/ 50% out-of-network, for more information see Evidence of Coverage
Diagnostic Procedures: Diagnostic Procedures/Tests: $50 in-network/ 50% out-of-network, for more information see Evidence of Coverage
Imaging: Xray: $50 in-network / CT Scans: $325 in-network / Diagnostic Radiology other than CT Scans: $325 in-network / Diagnostic Radiology Mammogram: $0 in-network / 50% out-of-network, for more information see Evidence of Coverage
Home Health Care
$0 in-network / 50% out-of-network
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $1871.00
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Out-of-Network:
Coinsurance for Psychiatric Hospital Services per Stay 50%
Mental Health Outpatient Care
Mental Health:
Group Sessions: $40 in-network/
Individual Sessions: $40 in-network/ 50% out-of-network, for more information see Evidence of Coverage

Psychiatric Services:
Group Sessions: $40 in-network/
Individual Sessions: $40 in-network/ 50% out-of-network, for more information see Evidence of Coverage
Outpatient Services / Surgery
Ambulatory Surgical Center: $275 in-network / ASC Screening Colonoscopy Polyp Removal and Post-FIT: $0 in-network / 50% 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 50%
Over-the-counter (OTC) Items
$90 quarterly OTC allowance, for more information see Evidence of Coverage
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $50.00
Out-of-Network:
Coinsurance for Medicare Covered Podiatry Services 50%
Skilled Nursing Facility Care
$0 per day, days 1-20
$196 per day, days 21-100

In-Network: 50% 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
Preventive dental services are covered, see the Evidence of Coverage.

Vision Benefits

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

Coverage Cost
Vision Benefits
$160 every year, see the Evidence of Coverage

Hearing Benefits

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

Coverage Cost
Hearing Benefits
Not Covered

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

Prescription Drug Costs and Coverage

The Aetna Medicare Choice Plan (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $250 (excludes Tiers 1 and 2) per year.

Coverage
Cost
Coverage & Cost
Annual Drug Deductible $250 (excludes Tiers 1 and 2)
Preferred Generic
  • Preferred cost-share retail $0.00
  • Standard retail $15.00
  • Preferred cost-share mail order $0.00
  • Standard mail order $15.00
Generic
  • Preferred cost-share retail $10.00
  • Standard retail $20.00
  • Preferred cost-share mail order $10.00
  • Standard mail order $20.00
Annual Drug Deductible $250 (excludes Tiers 1 and 2)
Preferred Generic
  • Preferred cost-share retail $0.00
  • Standard retail $30.00
  • Preferred cost-share mail order $0.00
  • Standard mail order $30.00
Generic
  • Preferred cost-share retail $20.00
  • Standard retail $40.00
  • Preferred cost-share mail order $20.00
  • Standard mail order $40.00
Annual Drug Deductible $250 (excludes Tiers 1 and 2)
Preferred Generic
  • Preferred cost-share retail $0.00
  • Standard retail $45.00
  • Preferred cost-share mail order $0.00
  • Standard mail order $45.00
Generic
  • Preferred cost-share retail $20.00
  • Standard retail $60.00
  • Preferred cost-share mail order $20.00
  • Standard mail order $60.00