Aetna Medicare Value Plan (HMO-POS)
Aetna Medicare Value Plan (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H3931-134.
Aetna Medicare Value Plan (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H3931-134.
Basic Costs and Coverage
Coverage | Cost |
---|---|
Monthly Deductible | $150 |
Out of Pocket Max |
In-Network: $7550 Out-of-Network: N/A |
Initial Coverage Limit | $4430 |
Catastrophic Coverage Limit | $7,050 |
Primary Care Doctor Visit | $0 |
Specialty Doctor Visit | $35 |
Inpatient Hospital Care | $315 per day, days 1-6; $0 per day, days 7-90 |
Urgent Care | Copayment for Urgent Care $0.00 to $45.00 Minimum copayment applies to urgently needed services provided in a PCP office. Maximum copayment applies to urgently needed services provided in an urgent care facility or location other than PCP. 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 | $250 |
Health Care Services and Medical Supplies
Aetna Medicare Value Plan (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 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 for services performed at a non-hospital facility in-network; $20 for services performed at a hospital facility/ $0 Lab Services: $0 in-network, for more information see Evidence of Coverage Diagnostic Procedures: Diagnostic Procedures/Tests: 20% in-network/ $0 Diagnostic Procedures/Tests: 0% in-network, for more information see Evidence of Coverage Imaging: Xray: $0 for services provided by your primary care physician in their office in-network; $100 for services performed by a provider other than your primary care physician in-network / CT Scans: $150 in-network / Diagnostic Radiology other than CT Scans: $150 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: $300.00 per day for days 1 to 6 $0.00 per day for days 7 to 90 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: $325 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 | $75 every three months, for more information see Evidence of Coverage |
Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $45.00 Copayment for Routine Foot Care $45.00
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Skilled Nursing Facility Care | $0 per day, days 1-20 $188 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 | $2,500 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 | $150 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 |
Prescription Drug Costs and Coverage
The Aetna Medicare Value Plan (HMO-POS) plan offers the following prescription drug coverage, with an annual drug deductible of $150 (excludes Tiers 1, 2 and 3) per year.
Coverage |
Cost
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---|---|
Coverage & Cost
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Annual Drug Deductible | $150 (excludes Tiers 1, 2 and 3) |
Preferred Generic |
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Generic |
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Preferred Brand |
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Annual Drug Deductible | $150 (excludes Tiers 1, 2 and 3) |
Preferred Generic |
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Generic |
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Preferred Brand |
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Annual Drug Deductible | $150 (excludes Tiers 1, 2 and 3) |
Preferred Generic |
|
Generic |
|
Preferred Brand |
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