Aetna Medicare Prime Plan (HMO) H3931:092-0 Plan Details

Arizona Counties Served

Maricopa County

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%