Aetna Medicare Value Plus Plan (HMO)
Aetna Medicare Value Plus Plan (HMO) H3146-012 Plan Details
Aetna Medicare Value Plus Plan (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H3146-012.
$18.00
Monthly Premium
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) H3146-012 Plan Details
Aetna Medicare Value Plus Plan (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H3146-012.
$18.00
Monthly Premium
Tennessee Counties Served
Bedford
Cannon
Cheatham
Clay
Coffee
Cumberland
Davidson
Dekalb
Dickson
Fentress
Franklin
Giles
Grundy
Hickman
Houston
Humphreys
Jackson
Lawrence
Lewis
Lincoln
Macon
Marshall
Maury
Montgomery
Moore
Overton
Perry
Pickett
Putnam
Robertson
Rutherford
Smith
Stewart
Sumner
Trousdale
Van Buren
Warren
Wayne
White
Williamson
Wilson
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
|
|
| 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 |
|
| Annual Drug Deductible | $95 (excludes Tiers 1, 2 and 3) |
| Preferred Generic |
|
| Generic |
|
| Preferred Brand |
|
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