Aetna Medicare Prime Plan (HMO) H3931:092-0 Plan Details
- Learn more about Aetna Medicare Platinum Plan (HMO) H3931:129-0, including plan costs, benefits and coverage details.
Arizona Counties Served
Plan Details and Plan Costs
Aetna Medicare Prime Plan (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered in Arizona by Aetna. The plan ID is H3931:092-0.
- Monthly Premium: $40.00
- Plan Deductible: $0.00
- Out of Pocket Spending Max: $7550
Primary Care Doctor Visit
$0.00 Copayment
Specialist Doctor Visit
$40.00 Copayment
Inpatient Hospital Care
$315 copayment per day, days 1-7
$0 copayment per day, days 8-90
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
$270.00 copayment
Additional Covered Health Care Services and Medical Supplies
Aetna Medicare Platinum Plan (HMO) 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
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
Medical Diagnostic Tests, Labs and Radiology Services
Lab Services: $0 in-network
- Lab Services related to COVID-19: $0 in-network, 40% out of network
Diagnostic Procedures/Tests: $30 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: $295 in-network
- Diagnostic Radiology other than CT Scans: $295 in-network
- Diagnostic Radiology Mammogram: $0 in-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
Chiropractic Services
In Network: $20.00 Copayment for Medicare-covered Chiropractic Services
Prior Authorization Required for Chiropractic Services
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
Prior Authorization Required for Psychiatric Hospital Services
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
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: $40.00
Dental Benefits
Not Covered
Vision Benefits
The following vision services are covered from in-network providers:
- $75 every year, see the Evidence of Coverage
Hearing Benefits
Not Covered
Preventive Services and Health/Wellness Education Programs
The following preventive services and wellness education programs are covered from in-network providers with $0.00 Copayment required.
Prescription Drug Costs and Coverage
The Aetna Medicare Platinum Plan (HMO) plan offers the following prescription drug coverage in Arizona, with an annual drug deductible of $100.00 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) $10.00
- Preferred Mail Order Cost Sharing (90 Day Supply) $25.00
- 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) 31%
- Standard Retail Cost Sharing (30 Day Supply) 31%


