Aetna Medicare Prime (HMO-POS)

Aetna Inc.
Aetna Medicare Prime (HMO-POS) H3192-001 Plan Details
Plan too new to be measured

Aetna Medicare Prime (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H3192-001.

$0.00
Monthly Premium

Aetna Medicare Prime (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H3192-001.

Aetna Inc.
Aetna Medicare Prime (HMO-POS) H3192-001 Plan Details
Plan too new to be measured

Aetna Medicare Prime (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H3192-001.

$0.00
Monthly Premium

Illinois Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $3950
Out-of-Network: N/A
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
$0
Specialty Doctor Visit
$20
Inpatient Hospital Care
$175 per day, days 1-7; $0 per day, days 8-90 in-network / $275 per day, days 1-7; $0 per day, days 8-90 out-of-network
Urgent Care
Copayment for Urgent Care $30.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $90.00
Emergency Room Visit
$90 If you are admitted to the hospital within 0 hours you do not have to pay your cost share may be waived, for more information see the Evidence of Coverage
Ambulance Transportation
$275

Health Care Services and Medical Supplies

Aetna Medicare Prime (HMO-POS) 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
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: $50 in-network/ $0 Diagnostic Procedures/Tests: $0 in-network, for more information see Evidence of Coverage
Imaging: Xray: $10 in-network / CT Scans: $125 in-network / Diagnostic Radiology other than CT Scans: $125 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 $1871.00
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Mental Health Outpatient Care
Mental Health:
Group Sessions: $40 in-network/
Individual Sessions: $40 in-network, for more information see Evidence of Coverage

Psychiatric Services:
Group Sessions: $40 in-network/
Individual Sessions: $40 in-network, for more information see Evidence of Coverage
Outpatient Services / Surgery
Ambulatory Surgical Center: $175 in-network / ASC Screening Colonoscopy Polyp Removal: $0 in-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
Over-the-counter (OTC) Items
CVS one-time kit and $120 every three months, for more information see Evidence of Coverage
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $0.00
Referral Required for Podiatry Services
Skilled Nursing Facility Care
$0 per day, days 1-20
$184 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
$3,000 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
$375 every year, see the Evidence of Coverage

Hearing Benefits

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

Coverage Cost
Hearing Benefits
$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