Aetna Medicare Dual Signature Choice (PPO D-SNP)

Aetna Inc.
Aetna Medicare Dual Signature Choice (PPO D-SNP) H2293-002 Plan Details
Plan too new to be measured

Aetna Medicare Dual Signature Choice (PPO D-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H2293-002

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

$31.50
Monthly Premium

Aetna Medicare Dual Signature Choice (PPO D-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H2293-002

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

Aetna Inc.
Aetna Medicare Dual Signature Choice (PPO D-SNP) H2293-002 Plan Details
Plan too new to be measured

Aetna Medicare Dual Signature Choice (PPO D-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H2293-002

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

$31.50
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $8850
Out-of-Network: N/A
Initial Coverage Limit $5030
Catastrophic Coverage Limit $8,000
Primary Care Doctor Visit
$0 - 12% based on level of Medicaid eligibility. For more information see Evidence of Coverage.
Specialty Doctor Visit
$0 - 20% based on level of Medicaid eligibility. For more information see Evidence of Coverage.
Inpatient Hospital Care
$0 - $1755 per stay based on level of Medicaid eligibility. For more information see Evidence of Coverage.
Urgent Care
Copayment for Urgent Care $0.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $0.00
Maximum Plan Benefit of $250000.00
Emergency Room Visit
$0 - $100 based on level of Medicaid eligibility. If you are admitted to the hospital within 24 hours your cost share may be waived. For more information see Evidence of Coverage.
Ambulance Transportation
$0 - 20% based on level of Medicaid eligibility. For more information see Evidence of Coverage.

Health Care Services and Medical Supplies

Aetna Medicare Dual Signature Choice (PPO D-SNP) 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 $0.00
Copayment for Routine Care $0.00
  • Maximum 12 Routine Care every year
Prior Authorization Required for Chiropractic Services
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Chiropractic Services 50% Coinsurance for Non-Medicare Covered Chiropractic Services 50%
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
0%
Durable Medical Eqipment (DME)
$0 - 18% based on level of Medicaid eligibility. For more information see Evidence of Coverage.
Diagnostic Tests, Lab and Radiology Services, and X-Rays
Lab Services: $0, for more information see Evidence of Coverage
Diagnostic Procedures: Diagnostic Procedures/Tests: $0 - 20% based on level of Medicaid eligibility| $0 Diagnostic Procedures/Tests: 0%, for more information see Evidence of Coverage
Imaging: Xray: $0 - 20% | CT Scans: $0 - 20% | Diagnostic Radiology other than CT Scans: $0 - 20% based on level of Medicaid eligibility| Diagnostic Radiology Mammogram: 0%. 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:
Copayment for Psychiatric Hospital Services per Stay $0.00
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Out-of-Network:
Copayment for Psychiatric Hospital Services per Stay $0.00
Mental Health Outpatient Care
$0 - 20% for Mental Health:
Group Sessions, $0 - 20% for Mental Health:
Individual Sessions based on level of Medicaid eligibility. For more information see Evidence of Coverage |$0 - 20% for Psychiatric Services:
Group Sessions, $0 - 20% for Psychiatric Services:
Individual Sessions based on level of Medicaid eligibility. For more information see Evidence of Coverage.
Outpatient Services / Surgery
Ambulatory Surgical Center: 0% in network for preventive and diagnostic colonoscopy |$0 - 20% based on level of Medicaid eligibilityfor all other ASC services, For more information see Evidence of Coverage
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $0.00
Copayment for Medicare-covered Group Sessions $0.00
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
Over the counter (OTC) items are covered under the Extra Benefits Card, for more information see Evidence of Coverage|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 $0.00
Copayment for Routine Foot Care $0.00
  • Maximum 12 visits every year
Out-of-Network:
Coinsurance for Medicare Covered Podiatry Services 40% Coinsurance for Non-Medicare Covered Podiatry Services 0%
Skilled Nursing Facility Care
$0 - $0 per day, days 1-20
$204 per day, days 21-100 based on level of Medicaid eligibility. 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:| $0 copay |Comprehensive dental services:| $0 copay |$3,500 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
In-Network:|Eye Exams:|Coinsurance for Medicare Covered Benefits 0%-20%|Copayment for Routine Eye Exams $0 |(Maximum one exam every year)|Eyewear:|Coinsurance for Medicare Covered Benefits 0%-20%|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 40%|Coinsurance for Routine Eye Exams 0%|Eyewear:|Coinsurance for Medicare-Covered Benefits 40%|Copayment for Non-Medicare covered Benefits $0|Maximum Plan Allowance for all Non-Medicare covered Eyewear $450 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:|Coinsurance for Medicare Covered Benefits 0%-20%|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 0% |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

Prescription Drug Costs and Coverage

The Aetna Medicare Dual Signature Choice (PPO D-SNP) plan offers the following prescription drug coverage, with an annual drug deductible of $0 per year.

Coverage
Cost
Coverage & Cost
Annual Drug Deductible $0
Preferred Generic
  • Preferred cost-share retail $0.00
  • Standard retail $0.00
  • Preferred cost-share mail order $0.00
  • Standard mail order $0.00
Generic
  • Preferred cost-share retail $0.00
  • Standard retail $0.00
  • Preferred cost-share mail order $0.00
  • Standard mail order $0.00
Preferred Brand
  • Preferred cost-share retail $0.00
  • Standard retail $0.00
  • Preferred cost-share mail order $0.00
  • Standard mail order $0.00
Non-Preferred Drug
  • Preferred cost-share retail $0.00
  • Standard retail $0.00
  • Preferred cost-share mail order $0.00
  • Standard mail order $0.00
Specialty Tier
  • Preferred cost-share retail $0.00
  • Standard retail $0.00
  • Preferred cost-share mail order $0.00
  • Standard mail order $0.00
Annual Drug Deductible $0
Preferred Generic
  • Preferred cost-share retail $0.00
  • Standard retail $0.00
  • Preferred cost-share mail order $0.00
  • Standard mail order $0.00
Generic
  • Preferred cost-share retail $0.00
  • Standard retail $0.00
  • Preferred cost-share mail order $0.00
  • Standard mail order $0.00
Preferred Brand
  • Preferred cost-share retail $0.00
  • Standard retail $0.00
  • Preferred cost-share mail order $0.00
  • Standard mail order $0.00
Non-Preferred Drug
  • Preferred cost-share retail $0.00
  • Standard retail $0.00
  • Preferred cost-share mail order $0.00
  • Standard mail order $0.00
Specialty Tier
  • Preferred cost-share retail N/A
  • Standard retail N/A
  • Preferred cost-share mail order N/A
  • Standard mail order N/A
Annual Drug Deductible $0
Preferred Generic
  • Preferred cost-share retail $0.00
  • Standard retail $0.00
  • Preferred cost-share mail order $0.00
  • Standard mail order $0.00
Generic
  • Preferred cost-share retail $0.00
  • Standard retail $0.00
  • Preferred cost-share mail order $0.00
  • Standard mail order $0.00
Preferred Brand
  • Preferred cost-share retail $0.00
  • Standard retail $0.00
  • Preferred cost-share mail order $0.00
  • Standard mail order $0.00
Non-Preferred Drug
  • Preferred cost-share retail $0.00
  • Standard retail $0.00
  • Preferred cost-share mail order $0.00
  • Standard mail order $0.00
Specialty Tier
  • Preferred cost-share retail N/A
  • Standard retail N/A
  • Preferred cost-share mail order N/A
  • Standard mail order N/A