Aetna Medicare Elite Plan (PPO)

Aetna Inc.
Aetna Medicare Elite Plan (PPO) H5521-118 Plan Details
4 out of 5 stars

Aetna Medicare Elite Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H5521-118.

$0.00
Monthly Premium

Aetna Medicare Elite Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H5521-118.

Aetna Inc.
Aetna Medicare Elite Plan (PPO) H5521-118 Plan Details
4 out of 5 stars

Aetna Medicare Elite Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H5521-118.

$0.00
Monthly Premium

New York Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $250
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
$10 in-network / $50 out-of-network
Specialty Doctor Visit
$40 in-network / $60 out-of-network
Inpatient Hospital Care
$750 per stay in-network / $500 per day, days 1-5; $0 per day, days 6-90 out-of-network
Urgent Care
Copayment for Urgent Care $50.00

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
$290 in-network / $290 out-of-network

Health Care Services and Medical Supplies

Aetna Medicare Elite 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:
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: $0 in-network/ $0 Lab Services: $0 in-network/ 30% out-of-network, for more information see Evidence of Coverage
Diagnostic Procedures: Diagnostic Procedures/Tests: $40 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: $200 in-network / Diagnostic Radiology other than CT Scans: $200 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: $175 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 $40.00
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
$500 reimbursement every year for preventive and comprehensive services, for more information see the 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 (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $250 (excludes Tiers 1 and 2) per year.

Coverage
Cost
Coverage & Cost
Annual Drug Deductible $250 (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 $250 (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 $250 (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