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2020 Medicare Advantage Plan Benefit Details for the Aetna Medicare Premier (PPO)


2020 Medicare Advantage Plan Details
Medicare Plan Name:Aetna Medicare Premier (PPO)
Location:Baker, Florida
Plan ID:H5521 - 033 - 0     Click to see other plans
Member Services:1-800-282-5366 TTY users 711
— Enrollment Options —
Medicare Contact Information:1-800-MEDICARE (1-800-633-4227)
TTY users 1-877-486-2048
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Email a copy of the Aetna Medicare Premier (PPO) benefit details
— Medicare Plan Features —
Monthly Premium:$0.00 (see Plan Premium Details below)
Annual Deductible:$300 (Tier 1 and 2 excluded from the Deductible.)
Annual Initial Coverage Limit (ICL):$4,020
Health Plan Type:Local PPO
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$6,700
Additional Gap Coverage?Yes, some additional gap coverage.
Total Number of Formulary Drugs:3,808 drugsBrowse the Aetna Medicare Premier (PPO) Formulary
This plan has 5 drug tiers. See cost-sharing for all pharmacies and tiers
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
Preferred Pharmacy
  Cost-Sharing during
  initial coverage phase:
$0.00$0.00$47.00$100.0027%
Number of Drugs per
  Tier:
3275739191329660
Plan's Pharmacy Search:http://www.aetnamedicare.com/findpharmacy
Plan Offers Mail Order?Yes
Number of Members enrolled in this plan in Baker, Florida:28 members
Number of Members enrolled in this plan in (H5521 - 033):16,737 members
Plan’s Summary Star Rating: 4.5 out of 5 Stars.
Customer Service Rating: 5 out of 5 Stars.
Member Experience Rating: 4 out of 5 Stars.
Drug Cost Accuracy Rating: 4 out of 5 Stars.
— Plan Premium Details —
The Monthly Premium is Split as Follows:
Total
Premium
Part C
Premium
Part D Base
Premium
Part D Supplemental
Premium
$0.00$0.00$0.00$0.00
Monthly Premium with Extra Help Low-Income Subsidy (LIS):100%
Subsidy
75%
Subsidy
50%
Subsidy
25%
Subsidy
Monthly Part D Premium with LIS:$0.00$0.00$0.00$0.00
Total Monthly Premium with LIS (Parts C & D):$0.00$0.00$0.00$0.00
— Plan Health Benefits —
** Base Plan **
Premium Total monthly premium: $0.00
  Health plan premium: $0.00
  Drug plan premium: $0.00
  Standard Part B premium: $135.50
  Part B premium reduction: No
Deductible Health plan deductible: $770 annual deductible
  Drug plan deductible: $300.00
Estimated yearly costs Estimated total yearly costs for care: $4,338.00
Out-of-pocket max Out-of-pocket max: $10,000 In and Out-of-network $6,700 In-network
Doctor services Primary doctor visit: In-network: $15 per visit Out-of-network: $50 per visit
  Specialist visit: In-network: $50 per visit Out-of-network: $50 per visit
Tests, labs, & imaging Diagnostic tests & procedures: In-network: $50 Out-of-network: 50%
  Lab services: In-network: $2 Out-of-network: 50%
  Diagnostic radiology services (like MRI): In-network: $125 Out-of-network: 50%
  Outpatient x-rays: In-network: $15 Out-of-network: 50%
  Emergency care: $90 per visit (always covered)
  Urgent care: $15-50 per visit (always covered)
Hospital services Inpatient hospital coverage: In-network: $395 per day for days 1 through 4 $0 per day for days 5 through 90 Out-of-network: 50% per stay
  Outpatient hospital coverage: In-network: $50-350 per visit Out-of-network: 50% per visit
Skilled nursing facility Skilled nursing facility: In-network: $0 per day for days 1 through 20 $178 per day for days 21 through 100 Out-of-network: 50% per stay
Preventive services Preventive services: In-network: $0 copay Out-of-network: $0 copay
Ambulance Ground ambulance: In-network: $260 Out-of-network: $260
Therapy services Occupational therapy visit: In-network: $40 Out-of-network: 50%
  Physical therapy & speech & language therapy visit: In-network: $40 Out-of-network: 50%
Mental health services Outpatient group therapy with a psychiatrist: In-network: $40 Out-of-network: 50%
  Outpatient individual therapy with a psychiatrist: In-network: $40 Out-of-network: 50%
  Outpatient group therapy visit: In-network: $40 Out-of-network: 50%
  Outpatient individual therapy visit: In-network: $40 Out-of-network: 50%
Opioid treatment services Opioid treatment services: Covered
Other services Durable medical equipment (like wheelchairs & oxygen): In-network: 20% per item Out-of-network: 50% per item
  Prosthetics (like braces, artificial limbs): In-network: 20% per item Out-of-network: 50% per item
  Diabetes supplies: In-network: 0-20% per item Out-of-network: 0-20% per item
Hearing Hearing exam: In-network: $50 Out-of-network: $50
  Fitting/evaluation: Not covered
  Hearing aids - Inner ear: Not covered
  Hearing aids - Outer ear: Not covered
  Hearing aids - Over the ear: Not covered
Preventive dental Oral exam: In-network: $0 copay Out-of-network: $0 copay
  Cleaning: In-network: $0 copay Out-of-network: $0 copay
  Fluoride treatment: In-network: $0 copay Out-of-network: $0 copay
  Dental x-rays: In-network: $0 copay Out-of-network: $0 copay
Comprehensive dental Non-routine services: In-network: $0 copay Out-of-network: $0 copay
  Diagnostic services: In-network: $0 copay Out-of-network: $0 copay
  Restorative services: In-network: $0 copay Out-of-network: $0 copay
  Endodontics: In-network: $0 copay Out-of-network: $0 copay
  Periodontics: In-network: $0 copay Out-of-network: $0 copay
  Extractions: In-network: $0 copay Out-of-network: $0 copay
  Prosthodontics, other oral/maxillofacial surgery, other services: In-network: $0 copay Out-of-network: $0 copay
Vision Routine eye exam: In-network: $0 copay Out-of-network: 50%
  Contact lenses: In-network: $0 copay Out-of-network: $0 copay
  Eyeglasses (frames & lenses): In-network: $0 copay Out-of-network: $0 copay
  Eyeglass frames (only): In-network: $0 copay Out-of-network: $0 copay
  Eyeglass lenses (only): In-network: $0 copay Out-of-network: $0 copay
  Upgrades: In-network: $0 copay Out-of-network: $0 copay
More benefits Fitness benefit: Limited coverage
  Over the counter drug benefits: Not covered
  In-home support services: Not covered
  Home and bathroom safety devices: Not covered
  Meals for short duration: Not covered
  Annual physical exams: Limited coverage
  Telehealth: Not covered
Part B drugs Chemotherapy drugs: In-network: 20% Out-of-network: 50%
  Other Part B drugs: In-network: 20% Out-of-network: 50%


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  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
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  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
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  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
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