Aetna Medicare Value Plus Plan (HMO)
Aetna Medicare Value Plus Plan (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H3146-012.
Aetna Medicare Value Plus Plan (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H3146-012.
Tennessee Counties Served
Basic Costs and Coverage
Coverage | Cost |
---|---|
Monthly Deductible | $95 |
Out of Pocket Max |
In-Network: $6700 Out-of-Network: N/A |
Initial Coverage Limit | $4660 |
Catastrophic Coverage Limit | $7,400 |
Primary Care Doctor Visit | $0 |
Specialty Doctor Visit | $25 |
Inpatient Hospital Care | $300 per day, days 1-5; $0 per day, days 6-90 |
Urgent Care | Copayment for Urgent Care $0.00 to $25.00 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 Maximum Plan Benefit of $250000.00 |
Emergency Room Visit | $90 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 | $260 |
Health Care Services and Medical Supplies
Aetna Medicare Value Plus Plan (HMO) 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 in-network, for more information see Evidence of Coverage Diagnostic Procedures: Diagnostic Procedures/Tests: $0 for services provided by your primary care physician in their office in-network; $75 for services performed by a provider other than your primary care physician in-network, for more information see Evidence of Coverage Imaging: Xray: $14 in-network / CT Scans: $0 for services provided by your primary care physician in their office in-network; $120 for services performed by a provider other than your primary care physician in-network / Diagnostic Radiology other than CT Scans: $0 for services provided by your primary care physician in their office in-network; $120 for services performed by a provider other than your primary care physician 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: $324.00 per day for days 1 to 5 $0.00 per day for days 6 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: $275 in-network / ASC Screening Colonoscopy Polyp Removal and Post-FIT: $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 | $105 quarterly OTC allowance, for more information see Evidence of Coverage |
Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $25.00 |
Skilled Nursing Facility Care | $0 per day, days 1-20 $196 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 | $300 reimbursement every year, for more information 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 Plus Plan (HMO) plan offers the following prescription drug coverage, with an annual drug deductible of $95 (excludes Tiers 1, 2 and 3) per year.
Coverage |
Cost
|
---|---|
Coverage & Cost
|
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Annual Drug Deductible | $95 (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 | $95 (excludes Tiers 1, 2 and 3) |
Preferred Generic |
|
Generic |
|
Preferred Brand |
|
Annual Drug Deductible | $95 (excludes Tiers 1, 2 and 3) |
Preferred Generic |
|
Generic |
|
Preferred Brand |
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