Aetna Medicare Elite (HMO)
Aetna Medicare Elite (HMO) H3931-104 Plan Details
Aetna Medicare Elite (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H3931-104.
$0.00
Monthly Premium
Aetna Medicare Elite (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H3931-104.
Aetna Medicare Elite (HMO) H3931-104 Plan Details
Aetna Medicare Elite (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H3931-104.
$0.00
Monthly Premium
Delaware Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $100 |
| Out of Pocket Max |
In-Network: $7550 Out-of-Network: N/A |
| Initial Coverage Limit | $4430 |
| Catastrophic Coverage Limit | $7,050 |
| Primary Care Doctor Visit | $30 |
| Specialty Doctor Visit | $50 |
| Inpatient Hospital Care | $550 per stay |
| Urgent Care | Copayment for Urgent Care $30.00 to $60.00 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 |
| 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 | $280 |
Health Care Services and Medical Supplies
Aetna Medicare Elite (HMO) 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 Referral Required for Chiropractic Services Prior authorization required |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | 0% - 20% Higher cost-share applies to non-OneTouch/LifeScan diabetic supplies. |
| Durable Medical Eqipment (DME) | 20% |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | Lab Services: Lab Services: $5 in-network/ $0 Lab Services: $0 in-network, for more information see Evidence of Coverage Diagnostic Procedures: Diagnostic Procedures/Tests: $35 in-network/ $0 Diagnostic Procedures/Tests: $0 in-network, for more information see Evidence of Coverage Imaging: Xray: $40 in-network / CT Scans: $30 for services provided by your primary care physician in their office in-network; $285 for services performed by a provider other than your primary care physician in-network / Diagnostic Radiology other than CT Scans: $30 for services provided by your primary care physician in their office in-network; $285 for services performed by a provider other than your primary care physician in-network / Diagnostic Radiology Mammogram: $0 in-network, for more information see Evidence of Coverage |
| Home Health Care | $0 |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital Services per Stay $1590.00 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required |
| Mental Health Outpatient Care | Mental Health: Group Sessions: $40 in-network/ Individual Sessions: $40 in-network, for more information see Evidence of Coverage Psychiatric Services: Group Sessions: $40 in-network/ Individual Sessions: $40 in-network, for more information see Evidence of Coverage |
| Outpatient Services / Surgery | Ambulatory Surgical Center: $250 in-network / ASC Screening Colonoscopy Polyp Removal: $0 in-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 |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $50.00 Referral Required for Podiatry Services |
| Skilled Nursing Facility Care | $0 per day, days 1-20 $188 per day, days 21-100 in-network, for more information see Evidence of Coverage |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | Not Covered |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | Not Covered |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | Not Covered |
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 |
Prescription Drug Costs and Coverage
The Aetna Medicare Elite (HMO) plan offers the following prescription drug coverage, with an annual drug deductible of $100 (excludes Tiers 1 and 2) per year.
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual Drug Deductible | $100 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $100 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $100 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
