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Aetna Medicare Advantra Premier (PPO) H5522-002 - H5522-002-000
$99.00
Monthly Premium
Aetna Medicare Advantra Premier (PPO) H5522-002 is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5522-002-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$99.00
Monthly Premium
Pennsylvania Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.
Most Medicare Advantage plans cover prescription drugs, and many plans may offer other additional benefits Original Medicare doesn’t cover.
Learn more about Pennsylvania Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $99.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $700.00 |
| Out-of-pocket maximum | $5,900.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,100.00 |
| Primary care doctor visit | In-Network $0 Out-of-Network 30% |
| Specialty doctor visit | In-Network $0 for services provided in a nursing home $30 for services provided outside a nursing home Out-of-Network 30% |
| Inpatient hospital care | In-Network $265 per day, days 1-7; $0 per day, days 8-90 Out-of-Network 30% per stay |
| Urgent care | Urgent Care: Copayment for Urgent Care $50 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $130 Maximum Plan Benefit of $250,000 |
| Emergency room visit | $130 If you are admitted to the hospital within 24 hours your cost share may be waived |
| Ambulance transportation | In-Network $250 Out-of-Network $250 |
Health Care Services and Medical Supplies
Aetna Medicare Advantra Premier (PPO) H5522-002 covers a range of additional benefits. Learn more about Aetna Medicare Advantra Premier (PPO) H5522-002 benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | In-Network $15 Out-of-Network 50% twelve visits every year |
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network 0% for continuous glucose monitors (CGM) at participating providers 0% for Accu-Chek/Roche and TRUE/Trividia blood glucose meters (BGM) and medical diabetic supplies 20% for blood glucose meters (BGM) and supplies manufactured by providers other than Accu-Chek/Roche and TRUE/Trividia with an approved prior authorization Out-of-Network 0% for Accu-Chek/Roche and TRUE/Trividia blood glucose meters (BGM) and medical diabetic supplies 30% for blood glucose meters (BGM) and supplies manufactured by providers other than Accu-Chek/Roche and TRUE/Trividia with an approved prior authorization 30% for continuous glucose monitors (CGM) |
| Durable medical equipment (DME) | In-Network 20% Out-of-Network 30% |
| Diagnostic tests, lab and radiology services, and X-rays | Lab Services: In-Network $0 Out-of-Network 20% Diagnostic Procedures: In-Network $0 Out-of-Network 20% Imaging: In-Network Xray: $30 CT Scans: $0 for services provided by your primary care provider in their office; $225 for services performed by a provider other than your primary care provider Diagnostic Radiology other than CT Scans: $0 for services provided by your primary care provider in their office; $225 for services performed by a provider other than your primary care provider Diagnostic Radiology Mammogram: $0 Out-of-Network 30% |
| Home health care | In-Network $0 Out-of-Network 30% |
| Mental health inpatient care | Out-of-Network: Psychiatric Hospital Services: Coinsurance for Psychiatric Hospital per Stay 30% |
| Mental health outpatient care | In-Network $40 for Mental Health - Group Sessions $40 for Mental Health - Individual Sessions $40 for Psychiatric Services - Group Sessions $40 for Psychiatric Services - Individual Sessions Out-of-Network 35% for Mental Health Services- Group Sessions 35% for Mental Health Services - Individual Sessions 35% for Psychiatric Services - Group Sessions 35% for Psychiatric Services - Individual Sessions |
| Outpatient services/surgery | Ambulatory Surgical Center: In-Network $0 for preventive and diagnostic colonoscopy $225 all other ambulatory surgical center services Out-of-Network 30% |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $40 Copayment for Medicare-covered Group Sessions $40 Prior Authorization Required for Outpatient Substance Abuse Services |
| Over-the-counter items | CVS Over-the-Counter (OTC) Wallet with a $30 quarterly benefit amount (allowance) on the Extra Benefits Card to help pay for approved OTC health and wellness products like first aid supplies, cold and allergy medicine, pain relievers, and more. Approved products can be purchased in-store at participating CVS retail locations (excluding locations inside other stores), using the app, online or by phone through CVS Flex Benefits. |
| Podiatry services | Out-of-Network: Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 30% |
| Skilled Nursing Facility (SNF) care | In-Network $10 per day, days 1-20; $221 per day, days 21-100 Out-of-Network 30% per stay |
Dental Benefits
The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Dental care | In-Network Preventive dental services: $0 for oral exams $0 for cleanings $0 for x-rays Comprehensive dental services: 20%-50% for restorative services 20% for endodontic services 20%-50% for periodontic services 50% for removeable prosthodontics 50% for fixed prosthodontics 20% - 50% for oral and maxillofacial surgery 20% - 50% for adjunctive services Out-of-Network Preventive dental services: 50% for oral exams 50% for cleanings 50% for x-rays Comprehensive dental services: 50% - 70% for restorative services 50% for endodontic services 50% - 70% for periodontic services 70% for removeable prosthodontics 70% for fixed prosthodontics 50% - 70% for oral and maxillofacial surgery 50% - 70% for adjunctive services $1,000 benefit amount (allowance) every year in and out-of-network for covered comprehensive dental services. Frequencies and medical necessity requirements vary by covered dental service. Covered preventive dental services do not count towards your annual benefit amount. See EOC for additional details on exclusions and limitations. |
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage
| Coverage | Details |
|---|---|
| Vision care | In-Network Eye Exams: $0 for Diabetic eye exams $30 for all other Medicare-covered eye exams $0 for non-Medicare covered routine eye exam with an EyeMed network provider Eyewear: $0 for Medicare-covered prescription eyewear $250 annual benefit amount (allowance) for non-Medicare covered prescription eyewear through an EyeMed network provider. $0 for Contacts $0 for Eyeglasses $0 for Eyeglass Frames $0 for Eyeglass Lenses $0 for Upgrades Out-of-Network Eye Exams: 30% for Medicare-covered eye exams $0 for non-Medicare covered routine eye exam (out of network covered up to $50) Eyewear: 30% for Medicare-covered prescription eyewear $250 annual benefit amount (allowance) for non-Medicare covered prescription eyewear $0 for Contacts $0 for Eyeglass Frames $0 for Eyeglass Lenses $0 for Eyeglass Lenses and Frames $0 for Upgrades Maximum one non-Medicare covered routine eye exam every calendar year in or out-of-network. Maximum one annual benefit amount for non-Medicare covered prescription eyewear in or out-of-network. |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | In-Network Hearing Exams: $30 for Medicare-covered hearing exams $0 for non-Medicare covered hearing exams (Maximum one non-Medicare covered hearing exam every year in or out-of-network) $0 for fitting/evaluation for hearing aids (Maximum one hearing aid fitting/evaluation every year) Hearing Aids: $0 for hearing aids $500 benefit amount (allowance) per ear, every year for hearing aids (Maximum two hearing aids every year) Out-of-Network: Hearing Exams: 30% for Medicare-covered hearing exams 30% for non-Medicare covered hearing exam every year in or out-of-network Hearing Aids: You must purchase hearing aids through NationsHearing |
Preventive Services and Health/Wellness Education Programs
The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Preventive services and health/wellness education programs | In-Network $0 for all preventive services covered under Original Medicare Out-of-Network 0% for the pneumonia, influenza, Hepatitis B, and Covid-19 vaccines 30% for all other preventive services covered under Original Medicare |
When reviewing Pennsylvania Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.
You may be able to find plans in your part of Pennsylvania that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Plan Documents
| Links to plan documents |
Pennsylvania Counties Served
We offer plans from Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, HealthspringSM or Kaiser Permanente.