H5521-801 Aetna Medicare Premier Plan (PPO) Detail

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Aetna offers a number of insurance plans with different costs. One of Aetna Insurance plans is Aetna Medicare Premier Plan (PPO) that is a PPO Medicare Advantage plan offered by Aetna with the plan ID of H5521-081 which covers prescription drugs.

You may have a plan to take the Aetna Medicare Premier Plan (PPO) but you need detailed information about this plan to convince you to take this Aetna plan. Thankfully, this post will show you the clear information about Aetna Medicare Premier Plan (PPO). So, let’s dive into our post to get the details!

What Are the Requirements to Take Aetna Medicare Premier Plan (PPO)?

To take the Aetna Medicare Premier Plan (PPO), you should be entitled to Medicare Part A and are enrolled in Medicare part B. Make sure you live in Aetna’s service area in North Carolina, including:

  • Alamance
  • Alexander
  • Anson
  • Burke
  • Cabarrus
  • Caldwell,
  •  Caswell
  • Catawba
  • Cleveland
  • Cumberland
  • Davidson
  • Davie
  • Forsyth
  • Gaston
  • Guilford
  • Iredell
  • Johnston
  • Lincoln
  • McDowell
  • Mecklenburg
  • Orange
  • Person
  • Randolph
  • Rockingham
  • Rowan
  • Stanly
  • Stokes
  • Union
  • Yadkin

Here are some things you have to know:

  • Primary Care Physician (PCP): You will have the option to select a PCP. Aetna can better support your care when Aetna knows who your doctor is.
  • Referrals: Aetna Medicare Premier Plan (PPO) will not require a referral from a PCP to see a specialist. You should know that some providers probably require a recommendation or treatment plan from your doctor in order to see you.
  • Prior Authorizations: The doctor will work with Aetna to get approval before you get certain services or drugs. The benefits which may require a prior authorization will be shown below.

Plan Costs for Aetna Medicare Premier Plan (PPO)

Monthly Plan Premium

  • In-network: $0
  • Out-of-network: $0

You may need to continue to pay your Medicare Part B premium.

Plan deductible

  • In-network: $0
  • Out-of-network: $0

Maximum out-of-pocket amount

  • In-network: $7,000
  • Out-of-network: $11.300 for in and out-of-network services combined.

Well, the most you pay for copays, coinsurance and other costs for the medical services for the year. After you reach the maximum out-of-pocket, Aetna’s plan will pay 100% of covered medical services. Your premium and prescription drugs will not count toward the maximum out-of-pocket.

Primary Benefits of Aetna Medicare Premier Plan (PPO)

Here’s a list of benefits you will get after you’re enrolled in Aetna Medicare Premier Plan (PPO):

Hospital coverage

The cost for in-network care:

  • Inpatient hospital coverage: $375 per day, days 1-4; $0 per day, days 5-90. You pay $0 for days 91 and beyond.
  • Outpatient hospital observation services: $375
  • Outpatient Hospital services: $35-$375
  • Ambulatory surgical center: $375

The cost for out-of-network care:

  • Inpatient hospital coverage: 50% per stay
  • Outpatient hospital observation services: 50%
  • Outpatient Hospital services: 50%
  • Ambulatory surgical center: 50%

Doctor Visits

The cost for in-network care:

  • Primary Care Physician (PCP): $0
  • Specialists: $35
  • Preventive Care: $0

The cost for out-of-network care:

  • Primary Care Physician (PCP): $55
  • Specialists: $60
  • Preventive Care: $0

Some preventive care include Abdominal aortic aneurysm screenings, alcohol misuse screening and counselling, breast cancer screening, HBV infection screening, etc.

Emergency and Urgent Care

  • Emergency care in the United States: $90
  • Urgently needed care in the United States: $0 – $35
  • Emergency & urgently needed care worldwide:
  1. Emergency care: $90
  2. Urgently needed care: $90
  3. Ambulance: $260

$250,000 maximum benefit for worldwide emergency and urgent care combined.

Diagnostic Testing

The cost for in-network care:

  • Diagnostic radiology: $0-$100
  • Lab Services: $0
  • Diagnostic tests and procedures: $0-75
  • Outpatient x-rays: $14

The cost for out-of-network care:

  • Diagnostic radiology: 50%
  • Lab Services: 50%
  • Diagnostic tests and procedures: 50%
  • Outpatient x-rays: 50%

To note, the lower cost sharing means the cost for services provided by your primary care physician in their office, while the higher cost sharing means the cost  for services performed by a provider other than your primary care physician.

Hearing, Dental & Vision

For these benefits which offer a reimbursement, you will be able to see any licensed provider who is eligible under Medicare.

The cost for in-network care:

  • Diagnostic hearing exam: $35
  • Routine hearing exam: $0
  • Hearing aids: Not covered
  • Dental services: $1,000 reimbursement every year
  • Glaucoma screening: $0
  • Diagnostic eye exams: $0-$35
  • Routine eye exam: $0
  • Contacts and eyeglasses: $100

The cost for out-of-network care:

  • Diagnostic hearing exam: $60
  • Routine hearing exam: $60
  • Hearing aids: Not covered
  • Dental services: –
  • Glaucoma screening: 50%
  • Diagnostic eye exams: $60
  • Routine eye exam: $60
  • Contacts and eyeglasses: –

Mental Health Services

The cost for in-network care:

  • Inpatient psychiatric stay: $375 per day, days 1-4;$0 per day, days 5 -90
  • Outpatient mental health therapy: $40
  • Outpatient psychiatric therapy: $40

The cost for out-of-network care:

  • Inpatient psychiatric stay: 50% per stay
  • Outpatient mental health therapy: 50%
  • Outpatient psychiatric therapy: 50%

Skilled Nursing

Skilled nursing facility (SNF)

  • The cost for in-network care: $0 per day, days 1-20; $184 per day, days 21-100
  • The cost for out-of-network care: 50% per stay

Therapy

  • The cost for in-network care: $35
  • The cost for out-of-network care: 50%

Ambulance & routine transportation

The cost for in-network care:

  • Ground ambulance: $260
  • Air Ambulance: $260
  • Routine transportation: Not covered

The cost for out-of-network care:

  • Ground ambulance: $260
  • Air Ambulance: $260
  • Routine transportation: Not covered

Medicare Part B Drugs

The cost for in-network care:

  • Chemotherapy drugs: 20%
  • Other Part B drugs: 20%

The cost for out-of-network care:

  • Chemotherapy drugs: 50%
  • Other Part B drugs: 50%

What Are the Steps for Prescription Drugs?

For prescription drugs, your costs are lower if you qualify for Extra Help. For formulary names, it uses B2 that you can use when referencing the list of covered drugs.

Stage 1: Deductible

The first step, you will need to pay the full cost of drugs until you reach your deductible. The deductible that applies to drugs on Tiers 4 and 5 will cost $150.

Stage 2: Initial Coverage

You may pay the costs below until your total drug costs reach $4,130.

Stage 3: Coverage gap

Aetna’s plan will offer some coverage in this stage and the coverage gap will last until your out-of-pocket drugs costs reach $6,550.

Stage 4: Catastrophic Coverage

In this stage, you will pay a small cost share for each drug.

  • For Generic Drugs, you need to pay the greater of 5% of the cost of the drug or $3.70
  • For Brand Name Drugs, you need to pay the greater of 5% of the cost of the drug or $9.20

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