Aetna Medicare Value Plan (HMO-POS)

Aetna Inc.
Aetna Medicare Value Plan (HMO-POS) H3931-134 Plan Details
3.5 out of 5 stars

Aetna Medicare Value Plan (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H3931-134.

$0.00
Monthly Premium

Aetna Medicare Value Plan (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H3931-134.

Aetna Inc.
Aetna Medicare Value Plan (HMO-POS) H3931-134 Plan Details
3.5 out of 5 stars

Aetna Medicare Value Plan (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H3931-134.

$0.00
Monthly Premium

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
  • Maximum 6 visits every year
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
Coverage & Cost
Annual Drug Deductible $150 (excludes Tiers 1, 2 and 3)
Preferred Generic
  • Preferred retail $0.00
  • Standard retail $15.00
  • Preferred mail order $0.00
  • Standard mail order $15.00
Generic
  • Preferred retail $5.00
  • Standard retail $20.00
  • Preferred mail order $5.00
  • Standard mail order $20.00
Preferred Brand
  • Preferred retail $47.00
  • Standard retail $47.00
  • Preferred mail order $47.00
  • Standard mail order $47.00
Annual Drug Deductible $150 (excludes Tiers 1, 2 and 3)
Preferred Generic
  • Preferred retail $0.00
  • Standard retail $30.00
  • Preferred mail order $0.00
  • Standard mail order $30.00
Generic
  • Preferred retail $10.00
  • Standard retail $40.00
  • Preferred mail order $10.00
  • Standard mail order $40.00
Preferred Brand
  • Preferred retail $94.00
  • Standard retail $94.00
  • Preferred mail order $94.00
  • Standard mail order $94.00
Annual Drug Deductible $150 (excludes Tiers 1, 2 and 3)
Preferred Generic
  • Preferred retail $0.00
  • Standard retail $45.00
  • Preferred mail order $0.00
  • Standard mail order $45.00
Generic
  • Preferred retail $10.00
  • Standard retail $60.00
  • Preferred mail order $10.00
  • Standard mail order $60.00
Preferred Brand
  • Preferred retail $141.00
  • Standard retail $141.00
  • Preferred mail order $141.00
  • Standard mail order $141.00