Aetna Medicare Essential Plan (PPO)

Aetna Inc.
Aetna Medicare Essential Plan (PPO) H5521-354 Plan Details
4 out of 5 stars

Aetna Medicare Essential Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H5521-354.

$0.00
Monthly Premium

Aetna Medicare Essential Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H5521-354.

Aetna Inc.
Aetna Medicare Essential Plan (PPO) H5521-354 Plan Details
4 out of 5 stars

Aetna Medicare Essential Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H5521-354.

$0.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $200
Out of Pocket Max In-Network: $7500
Out-of-Network: N/A
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
$0 in-network / $55 out-of-network
Specialty Doctor Visit
$50 in-network / $60 out-of-network
Inpatient Hospital Care
$400 per day, days 1-5; $0 per day, days 6-90 in-network / 50% per stay out-of-network
Urgent Care
Copayment for Urgent Care $0.00 to $50.00

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
Maximum Plan Benefit of $250000.00
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
$260 in-network / $260 out-of-network

Health Care Services and Medical Supplies

Aetna Medicare Essential 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 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 / 45% 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/ 50% out-of-network, for more information see Evidence of Coverage
Diagnostic Procedures: Diagnostic Procedures/Tests: $0 for services provided by your primary care physician in their office in-network; $75 for services performed by a provider other than your primary care physician/ $0 Diagnostic Procedures/Tests: $0 in-network/ 50% out-of-network, for more information see Evidence of Coverage
Imaging: Xray: $14 in-network / CT Scans: $0 for services provided by your primary care physician in their office in-network; $120 for services performed by a provider other than your primary care physician in-network / Diagnostic Radiology other than CT Scans: $0 for services provided by your primary care physician in their office in-network; $120 for services performed by a provider other than your primary care physician 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:
$400.00 per day for days 1 to 4
$0.00 per day for days 5 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: $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
$45 every three months, for more information see Evidence of Coverage
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $50.00
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: 50% 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
$550 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
$115 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
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 Essential Plan (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $200 (excludes Tiers 1 and 2) per year.

Coverage
Cost
Coverage & Cost
Annual Drug Deductible $200 (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 $10.00
  • Standard retail $20.00
  • Preferred mail order $10.00
  • Standard mail order $20.00
Annual Drug Deductible $200 (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 $20.00
  • Standard retail $40.00
  • Preferred mail order $20.00
  • Standard mail order $40.00
Annual Drug Deductible $200 (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 $25.00
  • Standard retail $60.00
  • Preferred mail order $25.00
  • Standard mail order $60.00