Aetna Medicare Premier Plus 1 (Regional PPO)
Aetna Medicare Premier Plus 1 (Regional PPO) R6694-003 Plan Details
Aetna Medicare Premier Plus 1 (Regional PPO) is a Regional PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: R6694-003.
$217.00
Monthly Premium
Aetna Medicare Premier Plus 1 (Regional PPO) is a Regional PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: R6694-003.
Aetna Medicare Premier Plus 1 (Regional PPO) R6694-003 Plan Details
Aetna Medicare Premier Plus 1 (Regional PPO) is a Regional PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: R6694-003.
$217.00
Monthly Premium
Ohio Counties Served
Adams
Allen
Ashland
Ashtabula
Athens
Auglaize
Belmont
Brown
Butler
Carroll
Champaign
Clark
Clermont
Clinton
Columbiana
Coshocton
Crawford
Cuyahoga
Darke
Defiance
Delaware
Erie
Fairfield
Fayette
Franklin
Fulton
Gallia
Geauga
Greene
Guernsey
Hamilton
Hancock
Hardin
Harrison
Henry
Highland
Hocking
Holmes
Huron
Jackson
Jefferson
Knox
Lake
Lawrence
Licking
Logan
Lorain
Lucas
Madison
Mahoning
Marion
Medina
Meigs
Mercer
Miami
Monroe
Montgomery
Morgan
Morrow
Muskingum
Noble
Ottawa
Paulding
Perry
Pickaway
Pike
Portage
Preble
Putnam
Richland
Ross
Sandusky
Scioto
Seneca
Shelby
Stark
Summit
Trumbull
Tuscarawas
Union
Van Wert
Vinton
Warren
Washington
Wayne
Williams
Wood
Wyandot
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $4900 Out-of-Network: N/A |
| Initial Coverage Limit | $4430 |
| Catastrophic Coverage Limit | $7,050 |
| Primary Care Doctor Visit | $5 in-network / 20% out-of-network |
| Specialty Doctor Visit | $20 in-network / 20% out-of-network |
| Inpatient Hospital Care | $200 per day, days 1-5; $0 per day, days 6-90 in-network / 20% per stay out-of-network |
| Urgent Care | Copayment for Urgent Care $5.00 to $25.00 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 | $150 in-network / $150 out-of-network |
Health Care Services and Medical Supplies
Aetna Medicare Premier Plus 1 (Regional 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/ $0 Lab Services: $0 in-network/ 20% out-of-network, for more information see Evidence of Coverage Diagnostic Procedures: Diagnostic Procedures/Tests: $0 in-network/ $0 Diagnostic Procedures/Tests: $0 in-network/ 20% out-of-network, for more information see Evidence of Coverage Imaging: Xray: $0 for services performed at a non-hospital facility in-network; $15 for services performed at a hospital facility in-network / CT Scans: $50 for services performed at a non-hospital facility in-network; $100 for services performed at a hospital facility in-network / Diagnostic Radiology other than CT Scans: $50 for services performed at a non-hospital facility in-network; $100 for services performed at a hospital facility 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: $200.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 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: $100 in-network / ASC Screening Colonoscopy Polyp Removal: $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 | $135 every three months, for more information see Evidence of Coverage |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $20.00 Copayment for Routine Foot Care $20.00
Out-of-Network: Coinsurance for Medicare Covered Podiatry Services 20% Coinsurance for Non-Medicare Covered Podiatry Services 20% |
| Skilled Nursing Facility Care | $0 per day, days 1-20 $188 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 | $200 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 |
