Aetna Medicare Eagle Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5521-323-000
New York 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 extra benefits Original Medicare doesn’t cover.
Learn more about New York Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
This H5521-323 plan is a Medicare Advantage special needs plan offered by Aetna with the Plan ID: H5521-323-000. This plan offers all the same benefits of Medicare Plan A and Plan B as well as additional benefits that gives you more coverage. Because of this some of the out-of-pocket costs and coverage might be different, so we've broken down all the details of this plan below!
Plan ID: H5521-323-000
Aetna Medicare Advantage Plan is coordinated care Medicare Advantage plan offered by Aetna for beneficiaries in New York. Below you will find more details on coverage, costs, and specific plan data for the H5521-323-000 plan.
|Monthly plan premium||$0.00|
|Initial drug coverage limit||$0.00|
|Catastrophic drug coverage limit||$7,400.00|
|Primary care doctor visit||$0 in-network / $25 out-of-network|
|Specialty doctor visit||$35 in-network / $55 out-of-network|
|Inpatient hospital care||$350 per day, days 1-5; $0 per day, days 6-90 in-network / 50% per stay out-of-network|
Copayment for Urgent Care $50.00
Copayment for Worldwide Urgent Coverage $95.00
|Emergency room visit||$95 If you are admitted to the hospital within 0 hours your cost share may be waived, for more information see the Evidence of Coverage|
|Ambulance transportation||$300 in-network / $300 out-of-network|
Aetna Medicare Eagle Plan (PPO) covers a range of additional benefits. Learn more about Aetna Medicare Eagle Plan (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
Copayment for Medicare-covered Chiropractic Services $20.00
Prior Authorization Required for Chiropractic Services
|Diabetes supplies, training, nutrition therapy and monitoring||0% - 20% Higher cost-share applies to non-OneTouch/LifeScan diabetic supplies.|
|Durable medical equipment (DME)||0% - 20% for each Medicare-covered durable medical equipment item / 0% for continuous glucose meters / 20% for all other Medicare-covered DME items / 50% out-of-network|
|Diagnostic tests, lab and radiology services, and X-rays||Lab Services: Lab Services: $0 in-network/ $30 out-of-network, for more information see Evidence of Coverage|
Diagnostic Procedures: Diagnostic Procedures/Tests: $35 in-network/ 50% out-of-network, for more information see Evidence of Coverage
Imaging: Xray: $35 in-network / CT Scans: $200 for CT/CAT scans in-network; $300 for all other complex imaging in-network / Diagnostic Radiology other than CT Scans: $200 for CT/CAT scans in-network; $300 for all other complex imaging in-network / Diagnostic Radiology Mammogram: $0 in-network / 50% out-of-network, for more information see Evidence of Coverage
|Home health care||$0 in-network / 50% out-of-network|
|Mental health inpatient care||In-Network:|
Psychiatric Hospital Services:
$374.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Prior Authorization Required for Psychiatric Hospital Services
|Mental health outpatient care||Mental Health - Group Sessions: $40 in-network/ Mental Health - Individual Sessions: $40 in-network/ 50% out-of-network, for more information see Evidence of Coverage Psychiatric Services - Group Sessions: $40 in-network/ Psychiatric Services - Individual Sessions: $40 in-network/ 50% out-of-network, for more information see Evidence of Coverage|
|Outpatient services/surgery||Ambulatory Surgical Center: $175 in-network / ASC Screening Colonoscopy Polyp Removal and Post-FIT: $0 in-network / 50% out-of-network, for more information see Evidence of Coverage|
|Outpatient substance abuse care||In-Network:|
Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $40.00
Copayment for Medicare-covered Group Sessions $40.00
Prior Authorization Required for Outpatient Substance Abuse Services
|Over-the-counter items|| In-Network:|
Over-The-Counter (OTC) items:
Copayment for Over-The-Counter (OTC) items $0
Nicotine Replacement Therapy(NRT) offered as a Part C OTC benefit
$45 quarterly OTC allowance, for more information see Evidence of Coverage
Copayment for Medicare-Covered Podiatry Services $35.00
|Skilled Nursing Facility (SNF) care||$0 per day, days 1-20; $196 per day, days 21-100 in-network/ 50% per stay out-of-network, for more information see Evidence of Coverage|
The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
|Dental care|| In-Network:|
Copayment for Oral Exams $0
Copayment for Dental X-Rays $0
Copayment for Prophylaxis (Cleaning) $0
Copayment for Fluoride Treatment $0
Copayment for Non-routine Services $0
Copayment for Diagnostic Services $0
Copayment for Restorative Services $0
Co-Insurance for Preventive Dental 20%
Non-Medicare Covered Comprehensive Dental 20%
Frequency limitations may apply. See the Schedule of Benefits in your
Evidence of Coverage.
$2,000 maximum benefit for preventive and comprehensive dental services
combined - see Evidence of Coverage.
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
|Vision benefits|| In-Network:|
Copayment for Medicare Covered Benefits $0-$35
Copayment for Routine Eye Exams $0
- Maximum one exam every year
Copayment for Medicare Covered Benefits $0
Copayment for Contacts $0
Copayment for Eyeglasses $0
Copayment for Eyeglass Frames $0
Copayment for Eyeglass Lenses $0
Copayment for Upgrades $0
Copayment for Medicare-Covered Benefits $55
Copayment for Routine Eye Exams $55
Coinsurance for Medicare-Covered Benefits 50%
Copayment for Non-Medicare covered Benefits $0
Maximum Plan Allowance for all Non-Medicare covered Eyewear $250
reimbursement every year. For more information, see the Evidence of Coverage
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
|Hearing benefits|| In-Network:|
Copayment for Medicare Covered Benefits $35
Copayment for Routine hearing Exams $0
- Maximum one exam every year
Copayment for Fitting/Evaluation for Hearing Aid $0
- Maximum one hearing aid
fitting/evaluation every year
Copayment for Hearing Aids $0
- Maximum two hearing aids every
Copayment for Medicare Covered Hearing Exams $55
Copayment for Non-Medicare Covered Hearing Exams $55
Member must purchase hearing aids through NationsHearing
$1,250 per ear every year, for more information see the Evidence of
The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
|Preventive services and health/wellness education programs||$0 copay for all preventive services covered under Original Medicare at zero cost sharing|
When reviewing New York 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 New York that offer similar benefits at similar or lower prices than the plan above. Call 1-877-890-1409 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
|Links to plan documents|
Medicare beneficiaries from New York may have access to Medicare Advantage plans from Aetna and other insurance companies.
Get help comparing your local plan options by calling to speak with a licensed insurance agent who can help you find out if your doctor and prescription drugs are covered by a Medicare Advantage plan in your area.
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