Aetna Medicare Freedom Plus Plan (PPO)
Aetna Medicare Freedom Plus Plan (PPO) H2293-008 Plan Details
Aetna Medicare Freedom Plus Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H2293-008.
$0.00
Monthly Premium
Aetna Medicare Freedom Plus Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H2293-008.
Aetna Medicare Freedom Plus Plan (PPO) H2293-008 Plan Details
Aetna Medicare Freedom Plus Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H2293-008.
$0.00
Monthly Premium
Georgia Counties Served
Appling
Baker
Barrow
Bartow
Clarke
Banks
Butts
Calhoun
Carroll
Catoosa
Chattahoochee
Chattooga
Clay
Coffee
Colquitt
Crisp
Dade
Dawson
Dougherty
Elbert
Emanuel
Evans
Fannin
Franklin
Gilmer
Gordon
Greene
Habersham
Hall
Harris
Hart
Heard
Irwin
Jackson
Jasper
Johnson
Laurens
Lee
Lumpkin
Madison
Marion
Meriwether
Morgan
Murray
Muscogee
Newton
Oconee
Oglethorpe
Pickens
Pierce
Pike
Putnam
Quitman
Rabun
Randolph
Schley
Stephens
Stewart
Sumter
Talbot
Taliaferro
Tattnall
Terrell
Tift
Toombs
Towns
Treutlen
Troup
Turner
Union
Upson
Walker
Walton
Ware
Washington
Webster
White
Wilkes
Worth
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $5500 Out-of-Network: N/A |
| Initial Coverage Limit | $4660 |
| Catastrophic Coverage Limit | $7,400 |
| Primary Care Doctor Visit | $0 in-network / $25 out-of-network |
| Specialty Doctor Visit | $30 in-network / $50 out-of-network |
| Inpatient Hospital Care | $350 per day, days 1-6; $0 per day, days 7-90 in-network / 35% per stay out-of-network |
| Urgent Care | Copayment for Urgent Care $30.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $110.00 Maximum Plan Benefit of $250000.00 |
| Emergency Room Visit | $110 If you are admitted to the hospital within 24 hours your cost share may be waived, for more information see the Evidence of Coverage |
| Ambulance Transportation | $275 in-network / $275 out-of-network |
Health Care Services and Medical Supplies
Aetna Medicare Freedom Plus 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 40% |
| 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 / 35% out-of-network |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | Lab Services: Lab Services: $0 for services provided by your primary care physician in their office in-network; $15 for services performed by a provider other than your primary care physician/ 40% 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; $95 for services performed by a provider other than your primary care physician/ 35% out-of-network, for more information see Evidence of Coverage Imaging: Xray: $0 for services provided by your primary care physician in their office in-network; $35 for services performed by a provider other than your primary care physician in-network / CT Scans: $225 in-network / Diagnostic Radiology other than CT Scans: $225 in-network / Diagnostic Radiology Mammogram: $0 in-network / 35% out-of-network, for more information see Evidence of Coverage |
| Home Health Care | $0 in-network / 40% out-of-network |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $298.00 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 35% |
| Mental Health Outpatient Care | Mental Health: Group Sessions: $30 in-network/ Individual Sessions: $30 in-network/ 35% out-of-network, for more information see Evidence of Coverage Psychiatric Services: Group Sessions: $30 in-network/ Individual Sessions: $30 in-network/ 35% out-of-network, for more information see Evidence of Coverage |
| Outpatient Services / Surgery | Ambulatory Surgical Center: $275 in-network / ASC Screening Colonoscopy Polyp Removal and Post-FIT: $0 in-network / 35% 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 35% |
| Over-the-counter (OTC) Items | $75 quarterly OTC allowance, for more information see Evidence of Coverage |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $30.00 Copayment for Routine Foot Care $30.00
Out-of-Network: Coinsurance for Medicare Covered Podiatry Services 35% Coinsurance for Non-Medicare Covered Podiatry Services 35% |
| Skilled Nursing Facility Care | $0 per day, days 1-20 $196 per day, days 21-100 In-Network: 35% 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 | $1,500 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 | $500 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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