Aetna Medicare Gold Plan (PPO)

Aetna Inc.
Aetna Medicare Gold Plan (PPO) H5521-122 Plan Details
3.5 out of 5 stars

Aetna Medicare Gold Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H5521-122.

$176.00
Monthly Premium

Aetna Medicare Gold Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H5521-122.

Aetna Inc.
Aetna Medicare Gold Plan (PPO) H5521-122 Plan Details
3.5 out of 5 stars

Aetna Medicare Gold Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H5521-122.

$176.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $7550
Out-of-Network: N/A
Initial Coverage Limit $4660
Catastrophic Coverage Limit $7,400
Primary Care Doctor Visit
$10 in-network / 20% out-of-network
Specialty Doctor Visit
$35 in-network / 20% out-of-network
Inpatient Hospital Care
$400 per stay in-network / 20% per stay out-of-network
Urgent Care
Copayment for Urgent Care $10.00 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 $95.00
Emergency Room Visit
$95 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
$250 in-network / $250 out-of-network

Health Care Services and Medical Supplies

Aetna Medicare Gold 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 $15.00
Prior Authorization Required for Chiropractic Services
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Chiropractic Services 20%
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 / 20% out-of-network
Diagnostic Tests, Lab and Radiology Services, and X-Rays
Lab Services: Lab Services: $0 in-network/ 20% out-of-network, for more information see Evidence of Coverage
Diagnostic Procedures: Diagnostic Procedures/Tests: $5 in-network/ 20% out-of-network, for more information see Evidence of Coverage
Imaging: Xray: $15 in-network / CT Scans: $10 for services provided by your primary care physician in their office in-network; $250 for services performed by a provider other than your primary care physician in-network / Diagnostic Radiology other than CT Scans: $10 for services provided by your primary care physician in their office in-network; $250 for services performed by a provider other than your primary care physician in-network / Diagnostic Radiology Mammogram: $0 in-network / 20% out-of-network, for more information see Evidence of Coverage
Home Health Care
$0 in-network / 20% out-of-network
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $1590.00
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Out-of-Network:
Coinsurance for Psychiatric Hospital Services per Stay 20%
Mental Health Outpatient Care
Mental Health:
Group Sessions: $40 in-network/
Individual Sessions: $40 in-network/ 20% out-of-network, for more information see Evidence of Coverage

Psychiatric Services:
Group Sessions: $40 in-network/
Individual Sessions: $40 in-network/ 20% out-of-network, for more information see Evidence of Coverage
Outpatient Services / Surgery
Ambulatory Surgical Center: $250 in-network / ASC Screening Colonoscopy Polyp Removal and Post-FIT: $0 in-network / 20% 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 20%
Over-the-counter (OTC) Items
$60 quarterly OTC allowance, for more information see Evidence of Coverage
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $35.00
Out-of-Network:
Coinsurance for Medicare Covered Podiatry Services 20%
Skilled Nursing Facility Care
$0 per day, days 1-20
$196 per day, days 21-100

In-Network: 20% 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
$1,000 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
$150 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
$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