Aetna Medicare Eagle Plus Plan (PPO)
Aetna Medicare Eagle Plus Plan (PPO) H2293-009 Plan Details
Aetna Medicare Eagle Plus Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H2293-009.
$0.00
Monthly Premium
Aetna Medicare Eagle Plus Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H2293-009.
Aetna Medicare Eagle Plus Plan (PPO) H2293-009 Plan Details
Aetna Medicare Eagle Plus Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H2293-009.
$0.00
Monthly Premium
Georgia Counties Served
Appling
Baker
Baldwin
Barrow
Bartow
Bryan
Clarke
Spalding
Paulding
Banks
Bibb
Burke
Butts
Calhoun
Carroll
Catoosa
Chatham
Chattahoochee
Chattooga
Cherokee
Clay
Clayton
Cobb
Coffee
Colquitt
Columbia
Coweta
Crawford
Crisp
Dade
Dawson
Dekalb
Dooly
Dougherty
Douglas
Effingham
Elbert
Emanuel
Evans
Fannin
Floyd
Forsyth
Franklin
Fulton
Gadsden
Gilmer
Glascock
Glynn
Gordon
Greene
Gwinnett
Habersham
Hall
Hancock
Haralson
Harris
Hart
Heard
Henry
Houston
Irwin
Jackson
Jasper
Jefferson
Johnson
Jones
Lamar
Laurens
Lee
Liberty
Lincoln
Lumpkin
Macon
Madison
Marion
Mcduffie
Mcintosh
Meriwether
Monroe
Morgan
Murray
Muscogee
Newton
Oconee
Oglethorpe
Peach
Pickens
Pierce
Pike
Polk
Putnam
Quitman
Rabun
Randolph
Richmond
Rockdale
Russell
Schley
Screven
Stephens
Stewart
Sumter
Talbot
Taliaferro
Tattnall
Taylor
Terrell
Tift
Toombs
Towns
Treutlen
Troup
Turner
Twiggs
Union
Upson
Walker
Walton
Ware
Warren
Washington
Wayne
Webster
White
Wilkes
Wilkinson
Worth
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 / $25 out-of-network |
| Specialty Doctor Visit | $35 in-network / $50 out-of-network |
| Inpatient Hospital Care | $308 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 | $250 in-network / $250 out-of-network |
Health Care Services and Medical Supplies
Aetna Medicare Eagle Plus 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; $75 for services performed by a provider other than your primary care physician in-network / CT Scans: $195 in-network / Diagnostic Radiology other than CT Scans: $195 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: $275 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 | $90 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: Coinsurance for Medicare Covered Podiatry Services 35% |
| 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 | $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 | $300 every year, see the Evidence of Coverage |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | $1,000 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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