Plan Basics
Contract Year 2020
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H5521-015-000
Plan Organization Aetna Medicare
Plan Type Local PPO
Plan Name Aetna Medicare Premier Plan (PPO)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Any Doctor
Benefit Type Enhanced Alternative
Special Needs Plan No
Overall Star Rating 4.5 Stars
Plan Cost Sharing
Premium $68.00
Total Premium (Includes Part B) $203.50
Monthly Part C Premium $41.90
Monthly Part D Basic Premium $16.60
Monthly Part D Supplemental Premium $9.50
Monthly Part D Total Premium $26.10
Monthly Part D Premium Full Assistance $9.50
Monthly Part D Premium 75% Assistance $13.60
Monthly Part D Premium 50% Assistance $17.80
Monthly Part D Premium 25% Assistance $21.90
Part D Drug Deductible $0.00
Part D Initial Coverage Limit $4020.00
Part D Catastrophic Coverage Threshold $6350.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $6700.00
Gap Coverage Yes
Formulary Website Formulary Link

Medicare Advantage Plan Health Benefits


Additional Benefits And/or Reduced Cost-sharing For Enrollees With Certain Health Conditions?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Extractions No - - - Not covered
Non-routine services No - - - Not covered
Periodontics No - - - Not covered
Diagnostic services No - - - Not covered
Prosthodontics, other oral/maxillofacial surgery, other services No - - - Not covered
Endodontics No - - - Not covered
Restorative services No - - - Not covered
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic tests and procedures - Out-of-Network Yes No 50%
Diagnostic radiology services (e.g., MRI) - Out-of-Network Yes No 50%
Lab services - Out-of-Network Yes No 50%
Outpatient x-rays - Out-of-Network Yes No 50%
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Specialist - Out-of-Network No No 50% per visit
Primary - Out-of-Network - - 50% per visit
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Urgent care - - - - $25-65 per visit (always covered)
Emergency - - - - $90 per visit (always covered)
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Routine foot care - - - - Not covered
Foot exams and treatment - Out-of-Network No No 50%
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - $250
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $1,200 annual deductible
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Hearing aids - outer ear No - - - Not covered
Hearing aids - over the ear No - - - Not covered
Hearing exam - In-Network No No $50
Hearing aids - inner ear No - - - Not covered
Fitting/evaluation Yes In-Network No No $50
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Durable medical equipment (e.g., wheelchairs, oxygen) - Out-of-Network Yes - 50% per item
Diabetes supplies - In-Network Yes - 0-20% per item
Prosthetics (e.g., braces, artificial limbs) - Out-of-Network Yes - 50% per item
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Outpatient group therapy visit - Out-of-Network Yes No 50%
Outpatient group therapy visit with a psychiatrist - In-Network Yes No $40
Outpatient individual therapy visit with a psychiatrist - Out-of-Network Yes No 50%
Inpatient hospital - psychiatric - In-Network Yes No $318 per day for days 1 through 5 $0 per day for days 6 through 90
Outpatient individual therapy visit - Out-of-Network Yes No 50%
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Routine eye exam Yes Out-of-Network No No 50%
Upgrades - - - - Not covered
Contact lenses No - - - Not covered
Eyeglass frames No - - - Not covered
Eyeglasses (frames and lenses) No - - - Not covered
Eyeglass lenses No - - - Not covered
Other No Out-of-Network No No 50%
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No 50% per stay
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - In-Network Yes - 20%
Other Part B drugs - In-Network Yes - 20%
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network Yes No $50-275 per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network No No 0-50%
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning No - - - Not covered
Fluoride treatment No - - - Not covered
Oral exam No - - - Not covered
Dental x-ray(s) No - - - Not covered
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - Out-of-Network Yes No 50%
Physical therapy and speech and language therapy visit - Out-of-Network Yes No 50%
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No 50% per stay
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Not covered
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No Covered
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $10,000 In and Out-of-network $6,700 In-network
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - No
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048
Plan Available in these Counties
District Of Columbia County, Washington D.C.

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