Aetna Medicare Discover Value Plan (PPO)
Aetna Medicare Discover Value Plan (PPO) H5521-340 Plan Details
Aetna Medicare Discover Value Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H5521-340.
$23.00
Monthly Premium
Aetna Medicare Discover Value Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H5521-340.
Aetna Medicare Discover Value Plan (PPO) H5521-340 Plan Details
Aetna Medicare Discover Value Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H5521-340.
$23.00
Monthly Premium
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $250 |
| Out of Pocket Max |
In-Network: $7550 Out-of-Network: N/A |
| Initial Coverage Limit | $4660 |
| Catastrophic Coverage Limit | $7,400 |
| Primary Care Doctor Visit | $0 in-network / $45 out-of-network |
| Specialty Doctor Visit | $30 in-network / $50 out-of-network |
| Inpatient Hospital Care | $325 per day, days 1-6; $0 per day, days 7-90 in-network / $500 per day, days 1-20; $0 per day, days 21-90 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 0 hours your cost share may be waived, for more information see the Evidence of Coverage |
| Ambulance Transportation | $300 in-network / $300 out-of-network |
Health Care Services and Medical Supplies
Aetna Medicare Discover Value 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 40% |
| 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 / 40% out-of-network |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | Lab Services: Lab Services: $0 in-network/ 40% out-of-network, for more information see Evidence of Coverage Diagnostic Procedures: Diagnostic Procedures/Tests: $30 in-network/ 40% out-of-network, for more information see Evidence of Coverage Imaging: Xray: $30 in-network / CT Scans: $175 for CT/CAT scans in-network; $225 for all other complex imaging in-network / Diagnostic Radiology other than CT Scans: $175 for CT/CAT scans in-network; $225 for all other complex imaging in-network / Diagnostic Radiology Mammogram: $0 in-network / 40% out-of-network, for more information see Evidence of Coverage |
| Home Health Care | $0 in-network / 40% out-of-network |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $374.00 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 40% |
| Mental Health Outpatient Care | Mental Health: Group Sessions: $40 in-network/ Individual Sessions: $40 in-network/ 40% out-of-network, for more information see Evidence of Coverage Psychiatric Services: Group Sessions: $40 in-network/ Individual Sessions: $40 in-network/ 40% out-of-network, for more information see Evidence of Coverage |
| Outpatient Services / Surgery | Ambulatory Surgical Center: $175 in-network / ASC Screening Colonoscopy Polyp Removal and Post-FIT: $0 in-network / 40% 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 40% |
| Over-the-counter (OTC) Items | $105 quarterly OTC allowance, for more information see Evidence of Coverage |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $30.00 Out-of-Network: Copayment for Medicare Covered Podiatry Services $50.00 |
| 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 | $1,500 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 | $200 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 |
Prescription Drug Costs and Coverage
The Aetna Medicare Discover Value 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 |
|
| Generic |
|
| Annual Drug Deductible | $250 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $250 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
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