Aetna Medicare Eagle Plan (PPO)
Aetna Medicare Eagle Plan (PPO) H5521-235 Plan Details
Aetna Medicare Eagle Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H5521-235.
$0.00
Monthly Premium
Aetna Medicare Eagle Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H5521-235.
Aetna Medicare Eagle Plan (PPO) H5521-235 Plan Details
Aetna Medicare Eagle Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H5521-235.
$0.00
Monthly Premium
Louisiana Counties Served
Acadia
Allen
Ascension
Avoyelles
Caldwell
Jefferson
Assumption
Beauregard
Bienville
Bossier
Caddo
Calcasieu
Cameron
Catahoula
Claiborne
De Soto
East Baton Rouge
East Feliciana
Evangeline
Franklin
Grant
Iberia
Iberville
Jackson
Jefferson Davis
La Salle
Lafayette
Lafourche
Lincoln
Livingston
Madison
Morehouse
Natchitoches
Orleans
Ouachita
Plaquemines
Pointe Coupee
Rapides
Red River
Richland
Sabine
Saint Bernard
Saint Charles
Saint Helena
Saint James
Saint Landry
Saint Martin
Saint Mary
Saint Tammany
St John The Baptist
Tangipahoa
Tensas
Terrebonne
Union
Vermilion
Vernon
Washington
Webster
West Baton Rouge
West Carroll
West Feliciana
Winn
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $-1 |
| Out of Pocket Max |
In-Network: $5900 Out-of-Network: N/A |
| Initial Coverage Limit | $0 |
| Catastrophic Coverage Limit | $7,400 |
| Primary Care Doctor Visit | $0 in-network / $30 out-of-network |
| Specialty Doctor Visit | $30 in-network / $50 out-of-network |
| Inpatient Hospital Care | $225 per day, days 1-7; $0 per day, days 8-90 in-network / 35% per stay out-of-network |
| Urgent Care | Copayment for Urgent Care $50.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $110.00 Maximum Plan Benefit of $250000.00 |
| Emergency Room Visit | $110 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 | $275 in-network / $275 out-of-network |
Health Care Services and Medical Supplies
Aetna Medicare Eagle 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: Copayment for Medicare Covered Chiropractic Services $50.00 |
| 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 / 35% out-of-network |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | Lab Services: Lab Services: $0 in-network/ 35% out-of-network, for more information see Evidence of Coverage Diagnostic Procedures: Diagnostic Procedures/Tests: $0 for services provided by your primary care physician in their office in-network; $95 for services performed by a provider other than your primary care physician/ 35% out-of-network, for more information see Evidence of Coverage Imaging: Xray: $0 for services provided by your primary care physician in their office in-network; $50 for services performed by a provider other than your primary care physician in-network / CT Scans: $150 in-network / Diagnostic Radiology other than CT Scans: $150 in-network / Diagnostic Radiology Mammogram: $0 in-network / 35% out-of-network, for more information see Evidence of Coverage |
| Home Health Care | $0 in-network / 35% out-of-network |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $295.00 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 35% |
| Mental Health Outpatient Care | Mental Health: Group Sessions: $30 in-network/ Individual Sessions: $30 in-network/ $50 out-of-network, for more information see Evidence of Coverage Psychiatric Services: Group Sessions: $30 in-network/ Individual Sessions: $30 in-network/ $50 out-of-network, for more information see Evidence of Coverage |
| Outpatient Services / Surgery | Ambulatory Surgical Center: $195 in-network / ASC Screening Colonoscopy Polyp Removal and Post-FIT: $0 in-network / 35% out-of-network, for more information see Evidence of Coverage |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $25.00 Copayment for Medicare-covered Group Sessions $25.00 Prior Authorization Required for Outpatient Substance Abuse Services Prior authorization required Out-of-Network: Copayment for Medicare Covered Individual or Group Sessions $50.00 |
| Over-the-counter (OTC) Items | $120 quarterly OTC allowance, for more information see Evidence of Coverage |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $35.00 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: 35% 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 | $2,500 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 | $500 every year, see the Evidence of Coverage |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | $2,000 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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