Aetna Medicare Value (PPO)
Aetna Medicare Value (PPO) H7301-007 Plan Details
Aetna Medicare Value (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H7301-007.
$0.00
Monthly Premium
Aetna Medicare Value (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H7301-007.
Aetna Medicare Value (PPO) H7301-007 Plan Details
Aetna Medicare Value (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc..
Plan ID: H7301-007.
$0.00
Monthly Premium
Illinois Counties Served
Adams
Brown
Cass
Christian
Clark
Clay
Coles
Crawford
Cumberland
Dewitt
Douglas
Edgar
Effingham
Fayette
Ford
Fulton
Iroquois
Jasper
Knox
La Salle
Livingston
Logan
Macon
Macoupin
Marshall
Mason
Mcdonough
Mclean
Menard
Montgomery
Morgan
Moultrie
Peoria
Piatt
Pike
Putnam
Richland
Sangamon
Schuyler
Scott
Shelby
Stark
Tazewell
Vermilion
Woodford
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $4650 Out-of-Network: N/A |
| Initial Coverage Limit | $4660 |
| Catastrophic Coverage Limit | $7,400 |
| Primary Care Doctor Visit | $0 in-network / 35% out-of-network |
| Specialty Doctor Visit | $40 in-network / 35% out-of-network |
| Inpatient Hospital Care | $300 per day, days 1-5; $0 per day, days 6-90 in-network / 35% per stay out-of-network |
| Urgent Care | Copayment for Urgent Care $40.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $110.00 |
| Emergency Room Visit | $110 If you are admitted to the hospital within 24 hours your cost share may be waived, for more information see the Evidence of Coverage |
| Ambulance Transportation | $295 in-network / $295 out-of-network |
Health Care Services and Medical Supplies
Aetna Medicare Value (PPO) 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 Out-of-Network: Coinsurance for Medicare Covered Chiropractic Services 35% |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | 0% - 20% Higher cost-share applies to non-OneTouch/LifeScan diabetic supplies. |
| Durable Medical Eqipment (DME) | 20% in-network / 35% out-of-network |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | Lab Services: Lab Services: $0 in-network/ 35% out-of-network, for more information see Evidence of Coverage Diagnostic Procedures: Diagnostic Procedures/Tests: $40 in-network/ 35% out-of-network, for more information see Evidence of Coverage Imaging: Xray: $0 in-network / CT Scans: $110 in-network / Diagnostic Radiology other than CT Scans: $110 in-network / Diagnostic Radiology Mammogram: $0 in-network / 35% out-of-network, for more information see Evidence of Coverage |
| Home Health Care | $0 in-network / 35% out-of-network |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $300.00 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 Out-of-Network: Coinsurance for Psychiatric Hospital Services per Stay 35% |
| Mental Health Outpatient Care | Mental Health: Group Sessions: $40 in-network/ Individual Sessions: $40 in-network/ 35% out-of-network, for more information see Evidence of Coverage Psychiatric Services: Group Sessions: $40 in-network/ Individual Sessions: $40 in-network/ 35% out-of-network, for more information see Evidence of Coverage |
| Outpatient Services / Surgery | Ambulatory Surgical Center: $250 in-network / ASC Screening Colonoscopy Polyp Removal and Post-FIT: $0 in-network / 35% out-of-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 Out-of-Network: Coinsurance for Medicare Covered Individual or Group Sessions 35% |
| Over-the-counter (OTC) Items | $75 quarterly OTC allowance, for more information see Evidence of Coverage |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $40.00 Copayment for Routine Foot Care $40.00
Out-of-Network: Coinsurance for Medicare Covered Podiatry Services 35% Coinsurance for Non-Medicare Covered Podiatry Services 35% |
| Skilled Nursing Facility Care | $10 per day, days 1-20 $196 per day, days 21-100 In-Network: 35% per stay Out-of-Network: for more information see Evidence of Coverage |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | $1,000 reimbursement every year for preventive and comprehensive services, for more information see the Evidence of Coverage |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | $210 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 |
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