Aetna Medicare Choice Plan (PPO)
Aetna Medicare Choice Plan (PPO) H5521-027 Plan Details
Aetna Medicare Choice Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5521-027
HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
$88.00
Monthly Premium
Aetna Medicare Choice Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5521-027
HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
Aetna Medicare Choice Plan (PPO) H5521-027 Plan Details
Aetna Medicare Choice Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5521-027
HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
$88.00
Monthly Premium
Virginia Counties Served
Spotsylvania
Fauquier
Augusta
Manassas City
Fredericksburg City
Petersburg City
Loudoun
Hanover
Fairfax
Emporia City
Alexandria City
Frederick
Stafford
Rappahannock
Manassas Park City
Waynesboro City
Prince George
Richmond City
Appomattox
Buckingham
Charles City
Amelia
Colonial Heights City
Chesterfield
Winchester City
Greensville
Henrico
Hopewell City
Warren
Falls Church City
Page
New Kent
Caroline
Arlington
Prince William
Dinwiddie
King William
Powhatan
Fairfax City
Staunton City
Nottoway
Cumberland
Goochland
Clarke
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $300 |
| Out of Pocket Max |
In-Network: $6700 Out-of-Network: N/A |
| Initial Coverage Limit | $5030 |
| Catastrophic Coverage Limit | $8,000 |
| Primary Care Doctor Visit | $5 in-network | 50% out-of-network |
| Specialty Doctor Visit | $50 in-network | 50% out-of-network |
| Inpatient Hospital Care | $300 per day, days 1-7; $0 per day, days 8-90 in-network | 50% per stay out-of-network |
| Urgent Care | Copayment for Urgent Care $40.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $100.00 |
| Emergency Room Visit | $100 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 | $270 in-network | $270 out-of-network |
Health Care Services and Medical Supplies
Aetna Medicare Choice Plan (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 $15.00 Prior Authorization Required for Chiropractic Services Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Chiropractic Services 50% |
| 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 | 50% out-of-network |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | Lab Services: Lab Services: $15 in-network| 50% out-of-network, for more information see Evidence of Coverage Diagnostic Procedures: Diagnostic Procedures/Tests: $10 for services provided by your primary care physician in their office in-network; $50 for services performed by a provider other than your primary care physician| 50% out-of-network, for more information see Evidence of Coverage Imaging: Xray: $5 for services provided by your primary care physician in their office in-network; $50 for services performed by a provider other than your primary care physician in-network | CT Scans: $300 in-network | Diagnostic Radiology other than CT Scans: $300 in-network | Diagnostic Radiology Mammogram: $0 in-network | 50% out-of-network, for more information see Evidence of Coverage |
| Home Health Care | $0 in-network | 50% out-of-network |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $318.00 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 50% |
| Mental Health Outpatient Care | Mental Health: Group Sessions: $45 in-network| Individual Sessions: $45 in-network| 50% out-of-network, for more information see Evidence of Coverage |Psychiatric Services: Group Sessions: $45 in-network| Individual Sessions: $45 in-network| 50% out-of-network, for more information see Evidence of Coverage |
| Outpatient Services / Surgery | Ambulatory Surgical Center: $0 in network for preventive and diagnostic colonoscopy | $325 All other in network ASC services | 50% 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 50% |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $50.00 Out-of-Network: Coinsurance for Medicare Covered Podiatry Services 50% |
| Skilled Nursing Facility Care | $0 per day, days 1-20 $203 per day, days 21-100 in-network| 50% 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 | In Network Dental Coverage|For covered services: ADA recognized dental services are covered excluding only cosmetic services, those considered medical in nature, and administrative changes.|Preventive dental services: |Oral exams: $0 copay |Cleanings: $0 copay |Fluoride treatment: $0 copay |Bitewing x-rays: $0 copay |Comprehensive dental services:|Non-routine services: $0 copay |Diagnostic services: $0 copay |Restorative services: $0 copay |Endodontics: $0 copay |Periodontics: $0 copay |Extractions: $0 copay |Prosthodontics and maxillofacial services: $0 copay |Out Of Network Dental Coverage|Preventive dental services:| 50% coinsurance |Comprehensive dental services:| 50% coinsurance |$2,000 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 | In-Network:|Eye Exams:|Copayment for Medicare Covered Benefits $0-$50|Copayment for Routine Eye Exams $0 |(Maximum one exam every year)|Eyewear:|Copayment for Medicare Covered Benefits $0|Copayment for Contacts $0|Copayment for Eyeglasses $0|Copayment for Eyeglass Frames $0|Copayment for Eyeglass Lenses $0|Copayment for Upgrades $0|Out-of-Network:|Eye Exams:|Coinsurance for Medicare-Covered Benefits 50%|Coinsurance for Routine Eye Exams 50%|Eyewear:|Coinsurance for Medicare-Covered Benefits 50%|Copayment for Non-Medicare covered Benefits $0|Maximum Plan Allowance for all Non-Medicare covered Eyewear $300 every year. See the Evidence of Coverage |
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 $50|Copayment for Routine hearing Exams $0|(Maximum one exam every year)|Copayment for Fitting/Evaluation for Hearing Aid $0|(Maximum one hearing aid fitting/evaluation every year)|Hearing Aids:|Copayment for Hearing Aids $0|(Maximum two hearing aids every year) |Out-of-Network:|Coinsurance for Medicare Covered Hearing Exams 50%|Coinsurance for Non-Medicare Covered Hearing Exams 50% |Member must purchase hearing aids through NationsHearing|$500 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 Choice Plan (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $300 (excludes Tiers 1 and 2) per year.
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual Drug Deductible | $300 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $300 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $300 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
