Aetna Medicare Platinum Plan (PPO) H5521:184-0 Plan Details
- Learn more about Aetna Medicare Platinum Plan (HMO) H3931:129-0, including plan costs, benefits and coverage details.
Arizona Counties Served
Plan Details and Plan Costs
Aetna Medicare Platinum Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered in Arizona by Aetna. The plan ID is H5521:184-0.
- Monthly Premium: $59.00
- Plan Deductible: $0.00
- Out of Pocket Spending Max: $6500
Primary Care Doctor Visit
$0.00 Copayment
Out of Network: 40% Coinsurance
Specialist Doctor Visit
$35.00 Copayment
Out of Network: 40% Coinsurance
Inpatient Hospital Care
$295 copayment per day, days 1-5
$0 copayment per day, days 6-90
Out of Network: 40% per stay
Urgent Care
Copayment for Urgent Care: $50.00
Copayment for Worldwide Urgent Coverage: $90.00
Emergency Room (ER) Visits
$90 copay
- 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
$260 copayment
Out of network: $260 copayment
Additional Covered Health Care Services and Medical Supplies
Aetna Medicare Platinum Plan (PPO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
Home Health Care
$0.00 copayment
Out of Network: 40% Coinsurance
Skilled Nursing Facility (SNF) Care
In Network:
- $0 per day days 1-20
- $184 per day, days 21-100
For more information see Evidence of Coverage
- Out of Network: 40% per stay, for more information see Evidence of Coverage
Medical Diagnostic Tests, Labs and Radiology Services
Lab Services: $0 in-network
- Lab Services related to COVID-19: $0 in-network
- Out of network: 40% Coinsurance
Diagnostic Procedures/Tests: $20 in-network,
- Diagnostic Procedures/Tests for COVID-19: $0 in-network
- For more information see Evidence of Coverage
Imaging:
- X-ray: $30 in-network
- CT Scans: $250 in-network
- Diagnostic Radiology other than CT Scans: $250 in-network
- Diagnostic Radiology Mammogram: $0 in-network
- 40% out of network
- For more information see Evidence of Coverage
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
Diabetic Supplies and Services:
- 0% - 20% coinsurance
- Higher cost-share applies to non-OneTouch/LifeScan diabetic supplies
Durable Medical Equipment (DME)
20% Coinsurance, 40% out of network
Chiropractic Services
In Network: $20.00 Copayment for Medicare-covered Chiropractic Services
Prior Authorization Required for Chiropractic Services
Out of Network: Coinsurance for Medicare Covered Chiropractic Services 40%
Mental Health Inpatient Care
In Network Psychiatric Hospital Services:
- $370.00 per day for days 1 to 5
- $0.00 per day for days 6 to 90
- Out of Network: Coinsurance for Psychiatric Hospital Services per Stay 40%
Prior Authorization Required for Psychiatric Hospital Services
Over-the-Counter (OTC) Items
$45 every three months.
- for more information see Evidence of Coverage
Mental Health Outpatient Care
In Network Psychiatric Services:
- Mental Health - Group Sessions: $40 in-network
- Mental Health - Individual Sessions: $40 in-network
- For more information see Evidence of Coverage
- Out of Network: Mental Health - Individual Sessions: 40% 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
Podiatry Services
In Network Copayment for Medicare-Covered Podiatry Services: $35.00
Dental Benefits
The following dental services are covered from in-network providers.
- $1000 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:
- $200 every year, see the Evidence of Coverage
Hearing Benefits
The following vision services are covered from in-network providers.
- $1250 per ear, see the Evidence of Coverage
Prescription Drug Costs and Coverage
The Aetna Medicare Platinum Plan (PPO) plan offers the following prescription drug coverage in Arizona, with an annual drug deductible of $0 per year.
Preferred Generic Drugs
- Preferred Retail Cost Sharing (30 Day Supply) $0.00
- Preferred Mail Order Cost Sharing (90 Day Supply) $0.00
- Standard Retail Cost Sharing (30 Day Supply) $15.00
- Standard Mail Order Cost Sharing (90 Day Supply) $45.00
Generic Drugs
- Preferred Retail Cost Sharing (30 Day Supply) $0.00
- Preferred Mail Order Cost Sharing (90 Day Supply) $0.00
- Standard Retail Cost Sharing (30 Day Supply) $20.00
- Standard Mail Order Cost Sharing (90 Day Supply) $60.00
Preferred Brand Name Drugs
- Preferred Retail Cost Sharing (30 Day Supply) $47.00
- Preferred Mail Order Cost Sharing (90 Day Supply) $141.00
- Standard Retail Cost Sharing (30 Day Supply) $47.00
- Standard Mail Order Cost Sharing (90 Day Supply) $141.00
Non-Preferred Drugs
- Preferred Retail Cost Sharing (30 Day Supply) $100.00
- Preferred Mail Order Cost Sharing (90 Day Supply) $300.00
- Standard Retail Cost Sharing (30 Day Supply) $100.00
- Standard Mail Order Cost Sharing (90 Day Supply) $300.00
Specialty Tier Drugs
- Preferred Retail Cost Sharing (30 Day Supply) 33%
- Standard Retail Cost Sharing (30 Day Supply) 33%


