Aetna Medicare Freedom Core Plan (PPO)
Aetna Medicare Freedom Core Plan (PPO) H3288-020 Plan Details
Aetna Medicare Freedom Core Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H3288-020.
$0.00
Monthly Premium
Aetna Medicare Freedom Core Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H3288-020.
Aetna Medicare Freedom Core Plan (PPO) H3288-020 Plan Details
Aetna Medicare Freedom Core Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H3288-020.
$0.00
Monthly Premium
Oklahoma Counties Served
Adair
Atoka
Canadian
Carter
Le Flore
Blaine
Bryan
Caddo
Cherokee
Cleveland
Coal
Cotton
Craig
Custer
Delaware
Garfield
Garvin
Grady
Grant
Haskell
Hughes
Jefferson
Johnston
Kay
Kingfisher
Latimer
Love
Major
Marshall
Mayes
Mcclain
Mcintosh
Murray
Muskogee
Noble
Nowata
Okfuskee
Osage
Ottawa
Pawnee
Pittsburg
Pontotoc
Pottawatomie
Pushmataha
Seminole
Sequoyah
Stephens
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $6700 Out-of-Network: N/A |
| Initial Coverage Limit | $4660 |
| Catastrophic Coverage Limit | $7,400 |
| Primary Care Doctor Visit | $0 in-network / 50% out-of-network |
| Specialty Doctor Visit | $40 in-network / 50% out-of-network |
| Inpatient Hospital Care | $260 per day, days 1-6; $0 per day, days 7-90 in-network / 40% per stay out-of-network |
| Urgent Care | Copayment for Urgent Care $0.00 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 $95.00 |
| Emergency Room Visit | $95 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 Freedom Core 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) | 18% in-network / 40% out-of-network |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | Lab Services: Lab Services: $0 in-network/ 50% out-of-network, for more information see Evidence of Coverage Diagnostic Procedures: Diagnostic Procedures/Tests: $50 in-network/ 50% out-of-network, for more information see Evidence of Coverage Imaging: Xray: $40 in-network / CT Scans: $375 in-network / Diagnostic Radiology other than CT Scans: $375 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 / $0 out-of-network |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital Services per Stay $1871.00 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: $325 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 $45.00 Copayment for Medicare-covered Group Sessions $45.00 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 | Seasonal Over-the-Counter (OTC) kit of preselected OTC items mailed twice a year and $120 quarterly OTC allowance, for more information see Evidence of Coverage |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $40.00 Out-of-Network: Coinsurance for Medicare Covered Podiatry Services 50% |
| Skilled Nursing Facility Care | $0 per day, days 1-20 $196 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 | $2,000 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 | $250 every year, 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 |
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