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Aetna Medicare Eagle (PPO)

Aetna Inc.
Aetna Medicare Eagle (PPO) H5521-286 Plan Details
3.5 out of 5 stars

Aetna Medicare Eagle (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H5521-286.

$0.00
Monthly Premium

Aetna Medicare Eagle (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H5521-286.

Aetna Inc.
Aetna Medicare Eagle (PPO) H5521-286 Plan Details
3.5 out of 5 stars

Aetna Medicare Eagle (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H5521-286.

$0.00
Monthly Premium

Illinois Counties Served

Boone Dupage Henry Bureau Carroll Cook Dekalb Grundy Hancock Henderson Jo Daviess Kane Kankakee Kendall Lake Lee Mchenry Mercer Ogle Rock Island Stephenson Warren Whiteside Will Winnebago

Indiana Counties Served

Adams Bartholomew Benton Boone Daviess Jasper Allen Blackford Brown Carroll Cass Clay Clinton Dekalb Delaware Elkhart Fountain Fulton Gibson Grant Greene Hamilton Hancock Hendricks Henry Howard Huntington Jackson Jay Jennings Johnson Knox Kosciusko La Porte Lagrange Lake Lawrence Madison Marion Marshall Martin Miami Monroe Montgomery Morgan Newton Noble Owen Parke Pike Porter Posey Pulaski Putnam Randolph Shelby St Joseph Starke Steuben Sullivan Tippecanoe Tipton Vanderburgh Vermillion Vigo Wabash Warren Warrick Wayne Wells White Whitley

Michigan Counties Served

Alcona Alger Allegan Arenac Clinton Genesee Macomb Alpena Antrim Baraga Bay Benzie Berrien Branch Calhoun Cass Charlevoix Cheboygan Chippewa Clare Crawford Delta Dickinson Eaton Emmet Gladwin Grand Traverse Gratiot Hillsdale Houghton Huron Ingham Iosco Iron Isabella Jackson Kalamazoo Kalkaska Kent Keweenaw Lake Lapeer Leelanau Lenawee Livingston Luce Mackinac Manistee Marquette Menominee Midland Missaukee Monroe Montcalm Montmorency Muskegon Oakland Oceana Ogemaw Ontonagon Oscoda Otsego Ottawa Presque Isle Roscommon Saginaw Saint Clair Saint Joseph Sanilac Schoolcraft Shiawassee Tuscola Washtenaw Wayne Wexford

Wisconsin Counties Served

Brown Columbia Green Kenosha Calumet Green Lake Kewaunee Lafayette Manitowoc Marquette Milwaukee Outagamie Ozaukee Racine Rock Shawano Sheboygan Walworth Washington Waukesha Waushara Winnebago

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $-1
Out of Pocket Max In-Network: $4390
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 / $55 out-of-network
Inpatient Hospital Care
$275 per day, days 1-7; $0 per day, days 8-90 in-network / 50% per stay out-of-network
Urgent Care
Copayment for Urgent Care $45.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $100.00
Emergency Room Visit
$100 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
$290 in-network / $290 out-of-network

Health Care Services and Medical Supplies

Aetna Medicare Eagle (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 / 25% out-of-network
Diagnostic Tests, Lab and Radiology Services, and X-Rays
Lab Services: Lab Services: $0 in-network/ $30 out-of-network, for more information see Evidence of Coverage
Diagnostic Procedures: Diagnostic Procedures/Tests: $75 in-network/ 50% out-of-network, for more information see Evidence of Coverage
Imaging: Xray: $20 in-network / CT Scans: $250 in-network / Diagnostic Radiology other than CT Scans: $250 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:
$275.00 per day for days 1 to 7
$0.00 per day for days 8 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: $350 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
$120 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 $55.00
Skilled Nursing Facility Care
$0 per day, days 1-20
$184 per day, days 21-100

In-Network: 45% 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
$3,000 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
$1,500 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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