Aetna Medicare Giveback Choice (PPO)
Aetna Medicare Giveback Choice (PPO) H5521-477 Plan Details
Aetna Medicare Giveback Choice (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5521-477
HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
$0.00
Monthly Premium
Aetna Medicare Giveback Choice (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5521-477
HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
Aetna Medicare Giveback Choice (PPO) H5521-477 Plan Details
Aetna Medicare Giveback Choice (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5521-477
HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
$0.00
Monthly Premium
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $250 |
| Out of Pocket Max |
In-Network: $8850 Out-of-Network: N/A |
| Initial Coverage Limit | $5030 |
| Catastrophic Coverage Limit | $8,000 |
| Primary Care Doctor Visit | $5 in-network | $20 out-of-network |
| Specialty Doctor Visit | $50 in-network | $50 out-of-network |
| Inpatient Hospital Care | $362 per day, days 1-7; $0 per day, days 8-90 in-network | 35% per stay out-of-network |
| Urgent Care | Copayment for Urgent Care $50.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $100.00 Maximum Plan Benefit of $250000.00 |
| Emergency Room Visit | $100 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 | $295 in-network | $295 out-of-network |
Health Care Services and Medical Supplies
Aetna Medicare Giveback Choice (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 $15.00 Prior Authorization Required for Chiropractic Services Prior authorization required Out-of-Network: Copayment for Medicare Covered Chiropractic Services $50.00 |
| 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 | 25% out-of-network |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | Lab Services: Lab Services: $5 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| $10 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: $5 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 | 50% out-of-network | CT Scans: $175 in-network | Diagnostic Radiology other than CT Scans: $175 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 | 35% out-of-network |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $295.00 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| $50 out-of-network, for more information see Evidence of Coverage |Psychiatric Services: Group Sessions: $30 in-network| Individual Sessions: $30 in-network| $50 out-of-network, for more information see Evidence of Coverage |
| Outpatient Services / Surgery | Ambulatory Surgical Center: $0 in network for preventive and diagnostic colonoscopy | $225 All other in network ASC services | 35% out-of-network, for more information see Evidence of Coverage |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $30.00 Copayment for Medicare-covered Group Sessions $30.00 Prior Authorization Required for Outpatient Substance Abuse Services Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Individual or Group Sessions 35% |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $50.00 Out-of-Network: Copayment for Medicare Covered Podiatry Services $50.00 |
| Skilled Nursing Facility Care | $0 per day, days 1-20 $203 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 | In Network Dental Coverage|For covered services: ADA recognized dental services are covered excluding only cosmetic services, those considered medical in nature, and administrative changes.|Preventive dental services: |Oral exams: $0 copay |Cleanings: $0 copay |Fluoride treatment: $0 copay |Bitewing x-rays: $0 copay |Comprehensive dental services:|Non-routine services: $0 copay |Diagnostic services: $0 copay |Restorative services: $0 copay |Endodontics: $0 copay |Periodontics: $0 copay |Extractions: $0 copay |Prosthodontics and maxillofacial services: $0 copay |Out Of Network Dental Coverage|Preventive dental services:| $0 copay |Comprehensive dental services:| $0 copay |$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 | In-Network:|Eye Exams:|Copayment for Medicare Covered Benefits $0-$50|Copayment for Routine Eye Exams $0 |(Maximum one exam every year)|Eyewear:|Copayment for Medicare Covered Benefits $0|Copayment for Contacts $0|Copayment for Eyeglasses $0|Copayment for Eyeglass Frames $0|Copayment for Eyeglass Lenses $0|Copayment for Upgrades $0|Out-of-Network:|Eye Exams:
|Copayment for Medicare-Covered Benefits $50|Copayment for Routine Eye Exams $50|Eyewear:|Coinsurance for Medicare-Covered Benefits 35%|Copayment for Non-Medicare covered Benefits $0|Maximum Plan Allowance for all Non-Medicare covered Eyewear $125 every year. See the Evidence of Coverage |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network:|Hearing Exams:|Copayment for Medicare Covered Benefits $50|Copayment for Routine hearing Exams $0|(Maximum one exam every year)|Copayment for Fitting/Evaluation for Hearing Aid $0|(Maximum one hearing aid fitting/evaluation every year)|Hearing Aids:|Copayment for Hearing Aids $0|(Maximum two hearing aids every year) |Out-of-Network:|Copayment for Medicare Covered Hearing Exams $50|Copayment for Non-Medicare Covered Hearing Exams $50 |Member must purchase hearing aids through NationsHearing|$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 |
Prescription Drug Costs and Coverage
The Aetna Medicare Giveback Choice (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 |
|
| Generic |
|
| Annual Drug Deductible | $250 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $250 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
