Aetna Medicare Platinum Plan (PPO) H5521:184-0 Plan Details

Arizona Counties Served

Pima County

Maricopa County

Pinal County

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%