Aetna Medicare Plus Plan 2 (HMO)

Aetna Inc.
Aetna Medicare Plus Plan 2 (HMO) H4982-015 Plan Details
Plan too new to be measured

Aetna Medicare Plus Plan 2 (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H4982-015.

$19.30
Monthly Premium

Aetna Medicare Plus Plan 2 (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H4982-015.

Aetna Inc.
Aetna Medicare Plus Plan 2 (HMO) H4982-015 Plan Details
Plan too new to be measured

Aetna Medicare Plus Plan 2 (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H4982-015.

$19.30
Monthly Premium

California Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $220
Out of Pocket Max In-Network: $7550
Out-of-Network: N/A
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
$0
Specialty Doctor Visit
$0
Inpatient Hospital Care
$1484 per stay
Urgent Care
Coinsurance for Urgent Care 20%

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $90.00
Emergency Room Visit
$90 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
20%

Health Care Services and Medical Supplies

Aetna Medicare Plus Plan 2 (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:
Coinsurance for Medicare-covered Chiropractic Services 20%
Copayment for Routine Care $0.00
Prior Authorization Required for Chiropractic Services
Referral 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/ $0 Lab Services: $0 in-network, for more information see Evidence of Coverage
Diagnostic Procedures: Diagnostic Procedures/Tests: 20% in-network/ $0 Diagnostic Procedures/Tests: 0% in-network, for more information see Evidence of Coverage
Imaging: Xray: 20% in-network / CT Scans: 20% in-network / Diagnostic Radiology other than CT Scans: 20% 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:
Copayment for Psychiatric Hospital Services per Stay $1484.00
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Mental Health Outpatient Care
Mental Health:
Group Sessions: 20% in-network/
Individual Sessions: 20% in-network, for more information see Evidence of Coverage

Psychiatric Services:
Group Sessions: 20% in-network/
Individual Sessions: 20% in-network, for more information see Evidence of Coverage
Outpatient Services / Surgery
Ambulatory Surgical Center: 20% in-network / ASC Screening Colonoscopy Polyp Removal: 0% in-network, for more information see Evidence of Coverage
Outpatient Substance Abuse Care
In-Network:
Coinsurance for Medicare-covered Individual Sessions 20%
Coinsurance for Medicare-covered Group Sessions 20%
Prior Authorization Required for Outpatient Substance Abuse Services
Prior authorization required
Over-the-counter (OTC) Items
$150 every three months
Podiatry Services
In-Network:
Coinsurance for Medicare-Covered Podiatry Services 20%
Coinsurance for Routine Foot Care 20%
  • Maximum 12 visits every year
Referral Required for Podiatry Services
Skilled Nursing Facility Care
$0 per day, days 1-20
$188 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 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
$400 every year, see the Evidence of Coverage

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
$2,500 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 Plus Plan 2 (HMO) plan offers the following prescription drug coverage, with an annual drug deductible of $220 (excludes Tiers 1 and 2) per year.

Coverage
Cost
Coverage & Cost
Annual Drug Deductible $220 (excludes Tiers 1 and 2)
Preferred Generic
  • Preferred retail $0.00
  • Standard retail $5.00
  • Preferred mail order $0.00
  • Standard mail order $5.00
Generic
  • Preferred retail $0.00
  • Standard retail $10.00
  • Preferred mail order $0.00
  • Standard mail order $10.00
Annual Drug Deductible $220 (excludes Tiers 1 and 2)
Preferred Generic
  • Preferred retail $0.00
  • Standard retail $10.00
  • Preferred mail order $0.00
  • Standard mail order $10.00
Generic
  • Preferred retail $0.00
  • Standard retail $20.00
  • Preferred mail order $0.00
  • Standard mail order $20.00
Annual Drug Deductible $220 (excludes Tiers 1 and 2)
Preferred Generic
  • Preferred retail $0.00
  • Standard retail $15.00
  • Preferred mail order $0.00
  • Standard mail order $15.00
Generic
  • Preferred retail $0.00
  • Standard retail $30.00
  • Preferred mail order $0.00
  • Standard mail order $30.00