Aetna Medicare Premier (PPO)

Aetna Inc.
Aetna Medicare Premier (PPO) H5521-389 Plan Details
3.5 out of 5 stars

Aetna Medicare Premier (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5521-389

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

$19.00
Monthly Premium

Aetna Medicare Premier (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5521-389

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

Aetna Inc.
Aetna Medicare Premier (PPO) H5521-389 Plan Details
3.5 out of 5 stars

Aetna Medicare Premier (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5521-389

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

$19.00
Monthly Premium

Wisconsin Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $150
Out of Pocket Max In-Network: $4100
Out-of-Network: N/A
Initial Coverage Limit $5030
Catastrophic Coverage Limit $8,000
Primary Care Doctor Visit
$0 in-network | $20 out-of-network
Specialty Doctor Visit
$30 in-network | $40 out-of-network
Inpatient Hospital Care
$235 per day, days 1-6; $0 per day, days 7-90 in-network | $335 per day, days 1-6; $0 per day, days 7-90 out-of-network
Urgent Care
Copayment for Urgent Care $45.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $110.00
Emergency Room Visit
$110 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
$285 in-network | $285 out-of-network

Health Care Services and Medical Supplies

Aetna Medicare Premier (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 $20.00
Prior Authorization Required for Chiropractic Services
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Chiropractic Services 50%
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 | 25% out-of-network
Diagnostic Tests, Lab and Radiology Services, and X-Rays
Lab Services: Lab Services: $0 in-network| $15 out-of-network, for more information see Evidence of Coverage
Diagnostic Procedures: Diagnostic Procedures/Tests: $75 in-network| 50% out-of-network, for more information see Evidence of Coverage
Imaging: Xray: $20 in-network | CT Scans: $225 in-network | Diagnostic Radiology other than CT Scans: $225 in-network | Diagnostic Radiology Mammogram: $0 in-network | 50% out-of-network, for more information see Evidence of Coverage
Home Health Care
$0 in-network | 50% out-of-network
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $1871.00
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Out-of-Network:
Coinsurance for Psychiatric Hospital Services per Stay 50%
Mental Health Outpatient Care
Mental Health:
Group Sessions: $40 in-network|
Individual Sessions: $40 in-network| 50% out-of-network, for more information see Evidence of Coverage |Psychiatric Services:
Group Sessions: $40 in-network|
Individual Sessions: $40 in-network| 50% out-of-network, for more information see Evidence of Coverage
Outpatient Services / Surgery
Ambulatory Surgical Center: $0 in network for preventive and diagnostic colonoscopy | $250 All other in network ASC services | 50% out-of-network, for more information see Evidence of Coverage
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $75.00
Copayment for Medicare-covered Group Sessions $75.00
Prior Authorization Required for Outpatient Substance Abuse Services
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Individual or Group Sessions 50%
Over-the-counter (OTC) Items
In Network: |Over-the-counter (OTC) items:|$75 quarterly amount (allowance) to purchase approved OTC health and wellness products like first aid supplies, cold and allergy medicine, pain relievers and more. Approved items can be purchased online, in store, or by phone. |Be sure to use the full benefit amount quarterly, because any unused amount will not rollover.|Nicotine Replacement Therapy(NRT) offered as a Part C OTC benefit.|Medium over-the-counter (OTC) kit of preselected OTC items mailed once a year, for more information see Evidence of Coverage
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $25.00
Out-of-Network:
Copayment for Medicare Covered Podiatry Services $40.00
Skilled Nursing Facility Care
$10 per day, days 1-20
$196 per day, days 21-100 in-network| 30% 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
In Network Dental Coverage|For covered services: ADA recognized dental services are covered excluding only cosmetic services, those considered medical in nature, and administrative changes.|Preventive dental services: |Oral exams: $0 copay |Cleanings: $0 copay |Fluoride treatment: $0 copay |Bitewing x-rays: $0 copay |Comprehensive dental services:|Non-routine services: $0 copay |Diagnostic services: $0 copay |Restorative services: $0 copay |Endodontics: $0 copay |Periodontics: $0 copay |Extractions: $0 copay |Prosthodontics and maxillofacial services: $0 copay |Out Of Network Dental Coverage|Preventive dental services:| 20% coinsurance |Comprehensive dental services:| 20% coinsurance |$1,650 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
In-Network:|Eye Exams:|Copayment for Medicare Covered Benefits $0-$30|Copayment for Routine Eye Exams $0 |(Maximum one exam every year)|Eyewear:|Copayment for Medicare Covered Benefits $0|Copayment for Contacts $0|Copayment for Eyeglasses $0|Copayment for Eyeglass Frames $0|Copayment for Eyeglass Lenses $0|Copayment for Upgrades $0|Out-of-Network:|Eye Exams: |Copayment for Medicare-Covered Benefits $40|Copayment for Routine Eye Exams $40|Eyewear:|Coinsurance for Medicare-Covered Benefits 50%|Copayment for Non-Medicare covered Benefits $0|Maximum Plan Allowance for all Non-Medicare covered Eyewear $150 every year. See the Evidence of Coverage

Hearing Benefits

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

Coverage Cost
Hearing Benefits
In-Network:|Hearing Exams:|Copayment for Medicare Covered Benefits $30|Copayment for Routine hearing Exams $0|(Maximum one exam every year)|Copayment for Fitting/Evaluation for Hearing Aid $0|(Maximum one hearing aid fitting/evaluation every year)|Hearing Aids:|Copayment for Hearing Aids $0|(Maximum two hearing aids every year) |Out-of-Network:|Copayment for Medicare Covered Hearing Exams $40|Copayment for Non-Medicare Covered Hearing Exams $40 |Member must purchase hearing aids through NationsHearing|$1,000 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 Premier (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $150 (excludes Tiers 1 and 2) per year.

Coverage
Cost
Coverage & Cost
Annual Drug Deductible $150 (excludes Tiers 1 and 2)
Preferred Generic
  • Standard mail order $5.00
  • Preferred cost-share retail $0.00
  • Standard retail $5.00
  • Preferred cost-share mail order $0.00
Generic
  • Standard mail order $10.00
  • Preferred cost-share retail $0.00
  • Standard retail $10.00
  • Preferred cost-share mail order $0.00
Annual Drug Deductible $150 (excludes Tiers 1 and 2)
Preferred Generic
  • Standard mail order $10.00
  • Preferred cost-share retail $0.00
  • Standard retail $10.00
  • Preferred cost-share mail order $0.00
Generic
  • Standard mail order $20.00
  • Preferred cost-share retail $0.00
  • Standard retail $20.00
  • Preferred cost-share mail order $0.00
Annual Drug Deductible $150 (excludes Tiers 1 and 2)
Preferred Generic
  • Standard mail order $15.00
  • Preferred cost-share retail $0.00
  • Standard retail $15.00
  • Preferred cost-share mail order $0.00
Generic
  • Standard mail order $30.00
  • Preferred cost-share retail $0.00
  • Standard retail $30.00
  • Preferred cost-share mail order $0.00