Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H3288-034-000
Plan Organization Aetna Medicare
Plan Type Local PPO *
Plan Name Aetna Medicare Eagle Plan (PPO)
Drugs Covered No
Doctors Choice Any Doctor
Overall Star Rating Plan too new to be measured
Plan Cost Sharing
Premium $0.00
Total Premium (Includes Part B) $135.50
Monthly Part C Premium $0.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $6900.00

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 - - $250 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 Yes Out-of-Network No No 35% coinsurance
Hearing aids Yes Out-of-Network No No $0 copay
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$6,900 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
Appling County, Georgia, Baker County, Georgia, Baldwin County, Georgia, Banks County, Georgia, Barrow County, Georgia, Bartow County, Georgia, Bibb County, Georgia, Bryan County, Georgia, Burke County, Georgia, Butts County, Georgia, Camden County, Georgia, Carroll County, Georgia, Catoosa County, Georgia, Chatham County, Georgia, Chattahoochee County, Georgia, Chattooga County, Georgia, Cherokee County, Georgia, Clarke County, Georgia, Clay County, Georgia, Clayton County, Georgia, Cobb County, Georgia, Coffee County, Georgia, Colquitt County, Georgia, Columbia County, Georgia, Coweta County, Georgia, Crawford County, Georgia, Crisp County, Georgia, Dawson County, Georgia, Dekalb County, Georgia, Dooly County, Georgia, Dougherty County, Georgia, Douglas County, Georgia, Effingham County, Georgia, Elbert County, Georgia, Emanuel County, Georgia, Evans County, Georgia, Fannin County, Georgia, Fayette County, Georgia, Floyd County, Georgia, Forsyth County, Georgia, Franklin County, Georgia, Fulton County, Georgia, Gilmer County, Georgia, Glynn County, Georgia, Gwinnett County, Georgia, Habersham County, Georgia, Hall County, Georgia, Hancock County, Georgia, Haralson County, Georgia, Harris County, Georgia, Hart County, Georgia, Heard County, Georgia, Henry County, Georgia, Houston County, Georgia, Irwin County, Georgia, Jackson County, Georgia, Jasper County, Georgia, Jefferson County, Georgia, Johnson County, Georgia, Jones County, Georgia, Lamar County, Georgia, Laurens County, Georgia, Lee County, Georgia, Liberty County, Georgia, Lincoln County, Georgia, Lumpkin County, Georgia, Macon County, Georgia, Madison County, Georgia, Marion County, Georgia, Mcduffie County, Georgia, Mcintosh County, Georgia, Meriwether County, Georgia, Monroe County, Georgia, Morgan County, Georgia, Murray County, Georgia, Muscogee County, Georgia, Newton County, Georgia, Oconee County, Georgia, Oglethorpe County, Georgia, Paulding County, Georgia, Peach County, Georgia, Pickens County, Georgia, Pierce County, Georgia, Pike County, Georgia, Polk County, Georgia, Quitman County, Georgia, Rabun County, Georgia, Randolph County, Georgia, Richmond County, Georgia, Rockdale County, Georgia, Schley County, Georgia, Screven County, Georgia, Spalding County, Georgia, Stephens County, Georgia, Stewart County, Georgia, Sumter County, Georgia, Tattnall County, Georgia, Taylor County, Georgia, Terrell County, Georgia, Tift County, Georgia, Toombs County, Georgia, Towns County, Georgia, Treutlen County, Georgia, Troup County, Georgia, Turner County, Georgia, Twiggs County, Georgia, Union County, Georgia, Upson County, Georgia, Walton County, Georgia, Ware County, Georgia, Warren County, Georgia, Washington County, Georgia, Wayne County, Georgia, White County, Georgia, Worth County, Georgia

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