Aetna Medicare Eagle Plan (PPO)
Aetna Medicare Eagle Plan (PPO) H5521-355 Plan Details
Aetna Medicare Eagle Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H5521-355.
$0.00
Monthly Premium
Aetna Medicare Eagle Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H5521-355.
Aetna Medicare Eagle Plan (PPO) H5521-355 Plan Details
Aetna Medicare Eagle Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H5521-355.
$0.00
Monthly Premium
Tennessee Counties Served
Bedford
Benton
Bledsoe
Cannon
Bradley
Carroll
Cheatham
Chester
Clay
Coffee
Crockett
Cumberland
Davidson
Decatur
Dekalb
Dickson
Dyer
Fayette
Fentress
Franklin
Gibson
Giles
Grundy
Hamilton
Hardeman
Hardin
Haywood
Henry
Hickman
Houston
Humphreys
Jackson
Lake
Lauderdale
Lawrence
Lewis
Lincoln
Macon
Marion
Marshall
Maury
Mcnairy
Meigs
Montgomery
Moore
Obion
Overton
Perry
Pickett
Polk
Putnam
Rhea
Robertson
Rutherford
Sequatchie
Shelby
Smith
Stewart
Sumner
Tipton
Trousdale
Van Buren
Warren
Wayne
Weakley
White
Williamson
Wilson
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $-1 |
| Out of Pocket Max |
In-Network: $6700 Out-of-Network: N/A |
| Initial Coverage Limit | $0 |
| Catastrophic Coverage Limit | $7,400 |
| Primary Care Doctor Visit | $0 in-network / $55 out-of-network |
| Specialty Doctor Visit | $35 in-network / $60 out-of-network |
| Inpatient Hospital Care | $250 per day, days 1-5; $0 per day, days 6-90 in-network / 50% per stay out-of-network |
| Urgent Care | Copayment for Urgent Care $0.00 to $35.00 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 $90.00 Maximum Plan Benefit of $250000.00 |
| Emergency Room Visit | $90 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 | $250 in-network / $250 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: 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: $0 for services provided by your primary care physician in their office in-network; $75 for services performed by a provider other than your primary care physician/ 50% out-of-network, for more information see Evidence of Coverage Imaging: Xray: $14 in-network / CT Scans: $0 for services provided by your primary care physician in their office in-network; $100 for services performed by a provider other than your primary care physician in-network / Diagnostic Radiology other than CT Scans: $0 for services provided by your primary care physician in their office in-network; $100 for services performed by a provider other than your primary care physician 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: $350.00 per day for days 1 to 4 $0.00 per day for days 5 to 90 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: $250 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 | $150 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 $60.00 |
| 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 | $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 | $300 reimbursement every year, for more information 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 |
Find Aetna Medicare Advantage Plans
Visit Aetna-MedicareAdvantage.com to compare Medicare Advantage plans, side by side.