Aetna Medicare Gold Advantage Prime (HMO)
Aetna Medicare Gold Advantage Prime (HMO) H2663-005 Plan Details
Aetna Medicare Gold Advantage Prime (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H2663-005.
$0.00
Monthly Premium
Aetna Medicare Gold Advantage Prime (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H2663-005.
Aetna Medicare Gold Advantage Prime (HMO) H2663-005 Plan Details
Aetna Medicare Gold Advantage Prime (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H2663-005.
$0.00
Monthly Premium
Illinois Counties Served
Missouri Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $2800 Out-of-Network: N/A |
| Initial Coverage Limit | $4660 |
| Catastrophic Coverage Limit | $7,400 |
| Primary Care Doctor Visit | $0 |
| Specialty Doctor Visit | $30 |
| Inpatient Hospital Care | $295 per day, days 1-8; $0 per day, days 9-90 |
| Urgent Care | Copayment for Urgent Care $35.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $125.00 |
| Emergency Room Visit | $125 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 | $280 |
Health Care Services and Medical Supplies
Aetna Medicare Gold Advantage Prime (HMO) 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 |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | 0% - 20% Higher cost-share applies to non-OneTouch/LifeScan diabetic supplies. |
| Durable Medical Eqipment (DME) | 20% |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | Lab Services: Lab Services: $0 in-network, for more information see Evidence of Coverage Diagnostic Procedures: Diagnostic Procedures/Tests: $30 in-network, for more information see Evidence of Coverage Imaging: Xray: $0 in-network / CT Scans: $100 in-network / Diagnostic Radiology other than CT Scans: $100 in-network / Diagnostic Radiology Mammogram: $0 in-network, for more information see Evidence of Coverage |
| Home Health Care | $0 |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $290.00 per day for days 1 to 8 $0.00 per day for days 9 to 90 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required |
| Mental Health Outpatient Care | Mental Health: Group Sessions: $30 in-network/ Individual Sessions: $40 in-network, for more information see Evidence of Coverage Psychiatric Services: Group Sessions: $30 in-network/ Individual Sessions: $40 in-network, for more information see Evidence of Coverage |
| Outpatient Services / Surgery | Ambulatory Surgical Center: $200 in-network / ASC Screening Colonoscopy Polyp Removal and Post-FIT: $0 in-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 $30.00 Prior Authorization Required for Outpatient Substance Abuse Services Prior authorization required |
| Over-the-counter (OTC) Items | Medium Over-the-Counter (OTC) kit of preselected OTC items mailed once a year and $60 quarterly OTC allowance, for more information see Evidence of Coverage |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $35.00 Copayment for Routine Foot Care $35.00
|
| Skilled Nursing Facility Care | $20 per day, days 1-20 $196 per day, days 21-100 in-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 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 | $300 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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