Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H1608-031-000
Plan Organization Aetna Medicare
Plan Type Local PPO
Plan Name Aetna Medicare Advantra Credit Value (PPO)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Any Doctor
Benefit Type Enhanced Alternative
Special Needs Plan No
Overall Star Rating 3.5
Plan Cost Sharing
Premium $0.00
Total Premium (Includes Part B) $100.50
Monthly Part C Premium $0.00
Monthly Part D Basic Premium $0.00
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $0.00
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $0.00
Monthly Part D Premium 50% Assistance $0.00
Monthly Part D Premium 25% Assistance $0.00
Part D Drug Deductible $195.00
Annual Drug Deductible $195.00
Tiers Excluded From Deductible 1
Part D Initial Coverage Limit $4130.00
Part D Catastrophic Coverage Threshold $6550.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $7550.00
Gap Coverage Yes

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
Diagnostic services No - - - Not covered
Endodontics No - - - Not covered
Extractions No - - - Not covered
Non-routine services No - - - Not covered
Periodontics No - - - Not covered
Prosthodontics, other oral/maxillofacial surgery, other services No - - - Not covered
Restorative services No - - - Not covered
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - Out-of-Network Yes No 40% coinsurance
Diagnostic tests and procedures - Out-of-Network Yes No 40% coinsurance
Lab services - Out-of-Network Yes No 40% coinsurance
Outpatient x-rays - Out-of-Network Yes No 40% coinsurance
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - Out-of-Network - - 40% coinsurance per visit
Specialist - Out-of-Network No No 40% coinsurance per visit
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $90 copay per visit (always covered)
Urgent care - - - - $60 copay per visit (always covered)
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - Out-of-Network No No 40% coinsurance
Routine foot care Yes Out-of-Network No No 40% coinsurance
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - $325 copay
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $1,600 annual deductible
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Fitting/evaluation Yes Out-of-Network No No 40% coinsurance
Hearing aids Yes Out-of-Network No No $0 copay
Hearing exam - Out-of-Network No No 40% coinsurance
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No 45% per stay
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $11,300 In and Out-of-network$7,550 In-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - Out-of-Network Yes - 0-20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen) - Out-of-Network Yes - 20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) - Out-of-Network Yes - 20% coinsurance per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - Out-of-Network Yes - 40% coinsurance
Other Part B drugs - Out-of-Network Yes - 40% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - Out-of-Network Yes No 45% per stay
Outpatient group therapy visit - Out-of-Network Yes No 45% coinsurance
Outpatient group therapy visit with a psychiatrist - Out-of-Network Yes No 45% coinsurance
Outpatient individual therapy visit - Out-of-Network Yes No 45% coinsurance
Outpatient individual therapy visit with a psychiatrist - Out-of-Network Yes No 45% coinsurance
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - No
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No 40% coinsurance per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network No No 0-40% coinsurance
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning No - - - Not covered
Dental x-ray(s) No - - - Not covered
Fluoride treatment No - - - Not covered
Oral exam No - - - Not covered
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - Out-of-Network Yes No 40% coinsurance
Physical therapy and speech and language therapy visit - Out-of-Network Yes No 40% coinsurance
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No 40% per stay
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Not covered
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses No - - - Not covered
Eyeglass frames No - - - Not covered
Eyeglass lenses No - - - Not covered
Eyeglasses (frames and lenses) No - - - Not covered
Other No Out-of-Network No No 40% coinsurance
Routine eye exam Yes Out-of-Network No No 40% coinsurance
Upgrades - - - - Not covered
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No Covered
Plan Drug Info
Formulary Link Drug Formulary Directory
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048
Plan Available in these Counties
Barbour County, West Virginia, Berkeley County, West Virginia, Boone County, West Virginia, Braxton County, West Virginia, Brooke County, West Virginia, Cabell County, West Virginia, Calhoun County, West Virginia, Clay County, West Virginia, Doddridge County, West Virginia, Fayette County, West Virginia, Gilmer County, West Virginia, Grant County, West Virginia, Greenbrier County, West Virginia, Hampshire County, West Virginia, Hancock County, West Virginia, Hardy County, West Virginia, Harrison County, West Virginia, Jackson County, West Virginia, Jefferson County, West Virginia, Kanawha County, West Virginia, Lewis County, West Virginia, Lincoln County, West Virginia, Logan County, West Virginia, Marion County, West Virginia, Marshall County, West Virginia, Mason County, West Virginia, Mcdowell County, West Virginia, Mercer County, West Virginia, Mineral County, West Virginia, Mingo County, West Virginia, Monongalia County, West Virginia, Monroe County, West Virginia, Morgan County, West Virginia, Nicholas County, West Virginia, Ohio County, West Virginia, Pendleton County, West Virginia, Pleasants County, West Virginia, Pocahontas County, West Virginia, Preston County, West Virginia, Putnam County, West Virginia, Raleigh County, West Virginia, Randolph County, West Virginia, Ritchie County, West Virginia, Roane County, West Virginia, Summers County, West Virginia, Taylor County, West Virginia, Tucker County, West Virginia, Tyler County, West Virginia, Upshur County, West Virginia, Wayne County, West Virginia, Webster County, West Virginia, Wetzel County, West Virginia, Wirt County, West Virginia, Wood County, West Virginia, Wyoming County, West Virginia

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