AVA (PPO)

AVA (PPO) H4961-008 Plan Details
Plan too new to be measured

AVA (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H4961-008.

$22.00
Monthly Premium

AVA (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H4961-008.

AVA (PPO) H4961-008 Plan Details
Plan too new to be measured

AVA (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H4961-008.

$22.00
Monthly Premium

California Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $3900
Out-of-Network: 9500
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $5.00
Out-of-Network:

Doctor Office Visit:
Copayment for Medicare Covered Primary Care Office Visit $40.00
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $20.00
Prior Authorization Required for Doctor Specialty Visit
Prior authorization required
Out-of-Network:

Doctor Specialty Visit:
Copayment for Medicare Covered Physician Specialist Office Visit $50.00
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$150.00 per day for days 1 to 3
$0.00 per day for days 4 to 90
Prior Authorization Required for Acute Hospital Services
Prior authorization required
Out-of-Network:
Coinsurance for Acute Hospital Services per Stay 20%
Urgent Care
Copayment for Urgent Care $20.00
Copayment for Medicare Covered Urgent Care waived if you are admitted to hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $0.00
Maximum Plan Benefit of $10,000
Emergency Room Visit
Copayment for Emergency Care $85.00

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $0.00
Maximum Plan Benefit of $10,000
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $250.00

Air Ambulance:
Copayment for Air Ambulance Services $250.00

Referral is required for non-emergency services. The copay does apply to each episode of an emergency transport that results in no admission. If it becomes necessary to transfer you to a different contracted facility for admission, the copay will be waived. Copay will still apply if ambulance is dispatched to members home and member refuses to be transported.
Please see Evidence of Coverage for Prior Authorization rules
Copayment waived if admitted to the hospital
Prior authorization required
Out-of-Network:

Ambulance Services:
Coinsurance for Medicare Covered Ambulance Services - Ground 30%
Coinsurance for Medicare Covered Ambulance Services - Air 30%

Health Care Services and Medical Supplies

AVA (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 $0.00
Prior Authorization Required for Chiropractic Services
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Chiropractic Services 30%
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Copayment for Medicare-covered Diabetic Supplies $0.00
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%
Prior Authorization Required for Diabetic Supplies and Services
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Diabetic Supplies and Services 30%
Durable Medical Eqipment (DME)
In-Network:

Durable Medical Equipment:
0% for items $350 or less
20% for items $350.01 or more
Prior Authorization Required for Durable Medical Equipment

Out-of-Network:

Durable Medical Equipment:
30% Coinsurance for Medicare Covered Durable Medical Equipment
Prior authorization required
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00
Copayment for Medicare-covered Lab Services $0.00

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $150.00
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $15.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Prior authorization required
Out-of-Network:

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 30%
Coinsurance for Medicare Covered Lab Services 30%
Coinsurance for Medicare Covered Diagnostic Radiological Services 30%
Coinsurance for Medicare Covered Therapeutic Radiological Services 30%
Coinsurance for Medicare Covered Outpatient X-Ray Services 30%
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Home Health 30%
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$120.00 per day for days 1 to 10
$0.00 per day for days 11 to 90
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Out-of-Network:
Coinsurance for Psychiatric Hospital Services per Stay 30%
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $0.00
Copayment for Medicare-covered Group Sessions $0.00
Prior Authorization Required for Outpatient Mental Health Services
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Individual Sessions 30%
Coinsurance for Medicare Covered Group Sessions 30%
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $165.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services $0.00
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $100.00
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
Out-of-Network:

Outpatient Hospital and ASC Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 25%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 30%
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 30%
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $0.00
Prior Authorization Required for Podiatry Services
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Podiatry Services 30%
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$100.00 per day for days 21 to 51
$0.00 per day for days 52 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Prior authorization required
Out-of-Network:
Coinsurance for Skilled Nursing Facility Services per Stay 30%

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
In-Network:

Comprehensive Dental:
Copayment for Medicare-covered Benefits $0.00
Prior Authorization Required for Comprehensive Dental
Prior authorization required
Out-of-Network:

Medicare Covered Dental Services:
Coinsurance for Medicare Covered Comprehensive Dental 30%

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Copayment for Contact Lenses $0.00
  • Maximum 1 Pair every two years
Copayment for Eyeglasses (lenses and frames) $0.00
  • Maximum 1 Pair every two years
Copayment for Eyeglass Lenses $0.00
  • Maximum 1 Pair every two years
Copayment for Eyeglass Frames $0.00
  • Maximum 1 Pair every two years
Maximum Plan Benefit of $150.00 every two years for all Non-Medicare covered eyewear
Prior Authorization Required for Eyewear
Prior authorization required
Out-of-Network:

Medicare Covered Vision Services:
Coinsurance for Medicare Covered Eye Exams 30%
Coinsurance for Medicare Covered Eyewear 30%
Non-Medicare Covered Vision Services:
Coinsurance for Non-Medicare Covered Eye Exams 30%
Coinsurance for Non-Medicare Covered Eyewear 50%

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $0.00
Copayment for Routine Hearing Exams $0.00
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00
  • Maximum 1 visit every year
Prior Authorization Required for Hearing Exams
Prior authorization required
Out-of-Network:

Medicare Covered Hearing Services:
Coinsurance for Medicare Covered Hearing Exams 30%
Non-Medicare Covered Hearing Services:
Coinsurance for Non-Medicare Covered Hearing Exams 30%

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
In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit
    Out-of-Network:

    Medicare-covered Zero Dollar Preventive Services:
    Coinsurance for Medicare Covered Medicare-covered Preventive Services 30%