Aetna Medicare Elite Plan 3 (PPO)

Aetna Inc.
Aetna Medicare Elite Plan 3 (PPO) H5521-310 Plan Details
4 out of 5 stars

Aetna Medicare Elite Plan 3 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H5521-310.

$25.00
Monthly Premium

Aetna Medicare Elite Plan 3 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H5521-310.

Aetna Inc.
Aetna Medicare Elite Plan 3 (PPO) H5521-310 Plan Details
4 out of 5 stars

Aetna Medicare Elite Plan 3 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H5521-310.

$25.00
Monthly Premium

New York Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $300
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
$0 in-network / $50 out-of-network
Specialty Doctor Visit
$35 in-network / $60 out-of-network
Inpatient Hospital Care
$795 per stay in-network / $500 per day, days 1-20; $0 per day, days 21-90 out-of-network
Urgent Care
Copayment for Urgent Care $65.00

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
$255 in-network / $255 out-of-network

Health Care Services and Medical Supplies

Aetna Medicare Elite Plan 3 (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 30%
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 / 30% out-of-network
Diagnostic Tests, Lab and Radiology Services, and X-Rays
Lab Services: Lab Services: $5 in-network/ $0 Lab Services: $0 in-network/ 30% out-of-network, for more information see Evidence of Coverage
Diagnostic Procedures: Diagnostic Procedures/Tests: $35 in-network/ $0 Diagnostic Procedures/Tests: $0 in-network/ 30% out-of-network, for more information see Evidence of Coverage
Imaging: Xray: $50 in-network / CT Scans: $295 in-network / Diagnostic Radiology other than CT Scans: $295 in-network / Diagnostic Radiology Mammogram: $0 in-network / 30% out-of-network, for more information see Evidence of Coverage
Home Health Care
$0 in-network / 30% out-of-network
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$374.00 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 30%
Mental Health Outpatient Care
Mental Health:
Group Sessions: $40 in-network/
Individual Sessions: $40 in-network/ 30% out-of-network, for more information see Evidence of Coverage

Psychiatric Services:
Group Sessions: $40 in-network/
Individual Sessions: $40 in-network/ 30% out-of-network, for more information see Evidence of Coverage
Outpatient Services / Surgery
Ambulatory Surgical Center: $200 in-network / ASC Screening Colonoscopy Polyp Removal: $0 in-network / 30% 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 30%
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
$188 per day, days 21-100

In-Network: 30% 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
$1,000 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
$100 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

Prescription Drug Costs and Coverage

The Aetna Medicare Elite Plan 3 (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $300 (excludes Tiers 1 and 2) per year.

Coverage
Cost
Coverage & Cost
Annual Drug Deductible $300 (excludes Tiers 1 and 2)
Preferred Generic
  • Preferred retail $0.00
  • Standard retail $15.00
  • Preferred mail order $0.00
  • Standard mail order $15.00
Generic
  • Preferred retail $0.00
  • Standard retail $20.00
  • Preferred mail order $0.00
  • Standard mail order $20.00
Annual Drug Deductible $300 (excludes Tiers 1 and 2)
Preferred Generic
  • Preferred retail $0.00
  • Standard retail $30.00
  • Preferred mail order $0.00
  • Standard mail order $30.00
Generic
  • Preferred retail $0.00
  • Standard retail $40.00
  • Preferred mail order $0.00
  • Standard mail order $40.00
Annual Drug Deductible $300 (excludes Tiers 1 and 2)
Preferred Generic
  • Preferred retail $0.00
  • Standard retail $45.00
  • Preferred mail order $0.00
  • Standard mail order $45.00
Generic
  • Preferred retail $0.00
  • Standard retail $60.00
  • Preferred mail order $0.00
  • Standard mail order $60.00