Aetna Medicare Eagle (PPO)
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.
Illinois Counties Served
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
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 |