Aetna Medicare Advantra Preferred Plan (PPO) | 2021 Medicare Advantage Plan

Plan Basics

Contract Year	2021
Medicare Type	Medicare Advantage Plan (Part C)
CMS Plan ID	H1608-028-000
Plan Organization	Aetna Medicare
Plan Type	Local PPO
Plan Name	Aetna Medicare Advantra Preferred 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	3.5

Plan Cost Sharing

Premium	$49.00
Total Premium (Includes Part B)	$184.50
Monthly Part C Premium	$17.60
Monthly Part D Basic Premium	$31.40
Monthly Part D Supplemental Premium	$0.00
Monthly Part D Total Premium	$31.40
Monthly Part D Premium Full Assistance	$1.60
Monthly Part D Premium 75% Assistance	$9.00
Monthly Part D Premium 50% Assistance	$16.50
Monthly Part D Premium 25% Assistance	$23.90
Part D Drug Deductible	$200.00
Annual Drug Deductible	$200.00
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	Yes	Out-of-Network	Yes	No	$0 copay
Endodontics	Yes	Out-of-Network	Yes	No	$0 copay
Extractions	Yes	Out-of-Network	Yes	No	$0 copay
Non-routine services	Yes	Out-of-Network	Yes	No	$0 copay
Periodontics	Yes	Out-of-Network	Yes	No	$0 copay
Prosthodontics, other oral/maxillofacial surgery, other services	Yes	Out-of-Network	Yes	No	$0 copay
Restorative services	Yes	Out-of-Network	Yes	No	$0 copay

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	35% coinsurance
Diagnostic tests and procedures	-	Out-of-Network	Yes	No	35% coinsurance
Lab services	-	Out-of-Network	Yes	No	35% coinsurance
Outpatient x-rays	-	Out-of-Network	Yes	No	35% coinsurance

Doctor Visits

Service	Cap	Network	Auth. Req.	Ref. Req.	Cost Share
Primary	-	Out-of-Network	-	-	35% coinsurance per visit
Specialist	-	Out-of-Network	No	No	35% 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	-	-	-	-	$50 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	35% coinsurance
Routine foot care	-	-	-	-	Not covered

Ground Ambulance

Service	Cap	Network	Auth. Req.	Ref. Req.	Cost Share
	-	Out-of-Network	-	-	$275 copay

Health Plan Deductible

Service	Cap	Network	Auth. Req.	Ref. Req.	Cost Share
	-	-	-	-	$0

Hearing

Service	Cap	Network	Auth. Req.	Ref. Req.	Cost Share
Fitting/evaluation	No	-	-	-	Not covered
Hearing aids - inner ear	No	-	-	-	Not covered
Hearing aids - outer ear	No	-	-	-	Not covered
Hearing aids - over the ear	No	-	-	-	Not covered
Hearing exam	-	Out-of-Network	No	No	35% coinsurance

Inpatient Hospital Coverage

Service	Cap	Network	Auth. Req.	Ref. Req.	Cost Share
	-	Out-of-Network	Yes	No	35% 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	-	35% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	-	Out-of-Network	Yes	-	35% coinsurance per item

Medicare Part B Drugs

Service	Cap	Network	Auth. Req.	Ref. Req.	Cost Share
Chemotherapy	-	Out-of-Network	Yes	-	35% coinsurance
Other Part B drugs	-	Out-of-Network	Yes	-	35% coinsurance

Mental Health Services

Service	Cap	Network	Auth. Req.	Ref. Req.	Cost Share
Inpatient hospital - psychiatric	-	Out-of-Network	Yes	No	35% per stay
Outpatient group therapy visit	-	Out-of-Network	Yes	No	35% coinsurance
Outpatient group therapy visit with a psychiatrist	-	Out-of-Network	Yes	No	35% coinsurance
Outpatient individual therapy visit	-	Out-of-Network	Yes	No	35% coinsurance
Outpatient individual therapy visit with a psychiatrist	-	Out-of-Network	Yes	No	35% 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	35% coinsurance per visit

Preventive Care

Service	Cap	Network	Auth. Req.	Ref. Req.	Cost Share
	-	Out-of-Network	No	No	$0 copay

Preventive Dental

Service	Cap	Network	Auth. Req.	Ref. Req.	Cost Share
Cleaning	Yes	Out-of-Network	No	No	$0 copay
Dental x-ray(s)	Yes	Out-of-Network	No	No	$0 copay
Fluoride treatment	Yes	Out-of-Network	No	No	$0 copay
Oral exam	Yes	Out-of-Network	No	No	$0 copay

Rehabilitation Services

Service	Cap	Network	Auth. Req.	Ref. Req.	Cost Share
Occupational therapy visit	-	Out-of-Network	Yes	No	35% coinsurance
Physical therapy and speech and language therapy visit	-	Out-of-Network	Yes	No	35% coinsurance

Skilled Nursing Facility

Service	Cap	Network	Auth. Req.	Ref. Req.	Cost Share
	-	Out-of-Network	Yes	No	35% 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	Yes	Out-of-Network	No	No	$0 copay
Eyeglass frames	Yes	Out-of-Network	No	No	$0 copay
Eyeglass lenses	Yes	Out-of-Network	No	No	$0 copay
Eyeglasses (frames and lenses)	Yes	Out-of-Network	No	No	$0 copay
Other	No	Out-of-Network	No	No	35% coinsurance
Routine eye exam	Yes	Out-of-Network	No	No	35% coinsurance
Upgrades	Yes	Out-of-Network	No	No	$0 copay

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

Bryan County, Georgia, Camden County, Georgia, Chatham County, Georgia, Cobb County, Georgia, Coweta County, Georgia, Dekalb County, Georgia, Douglas County, Georgia, Fayette County, Georgia, Fulton County, Georgia, Liberty County, Georgia, Mcintosh County, Georgia, Newton County, Georgia, Paulding County, Georgia, Rockdale County, Georgia

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