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Aetna Medicare Platinum Plan (PPO) - H5521-200-000
$77.00
Monthly Premium
Aetna Medicare Platinum Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5521-200-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$77.00
Monthly Premium
Arizona 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 Arizona 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 | $77.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $175.00 |
| Out-of-pocket maximum | $5,800.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $7,400.00 |
| Primary care doctor visit | $0 in-network / 40% out-of-network |
| Specialty doctor visit | $45 in-network / 40% out-of-network |
| Inpatient hospital care | $280 per day, days 1-5; $0 per day, days 6-90 in-network / 40% per stay out-of-network |
| Urgent care | Urgent Care: Copayment for Urgent Care $60.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $110.00 |
| Emergency room visit | $110 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 |
Health Care Services and Medical Supplies
Aetna Medicare Platinum Plan (PPO) covers a range of additional benefits. Learn more about Aetna Medicare Platinum Plan (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | Out-of-Network: Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 40% |
| Diabetes supplies, training, nutrition therapy and monitoring | 0% - 20% Higher cost-share applies to non-OneTouch/LifeScan diabetic supplies. |
| Durable medical equipment (DME) | 20% in-network / 40% out-of-network |
| Diagnostic tests, lab and radiology services, and X-rays | Lab Services: Lab Services: $0 in-network/ 40% out-of-network, for more information see Evidence of Coverage Diagnostic Procedures: Diagnostic Procedures/Tests: $45 in-network/ 40% out-of-network, for more information see Evidence of Coverage Imaging: Xray: $20 in-network / CT Scans: $250 in-network / Diagnostic Radiology other than CT Scans: $250 in-network / Diagnostic Radiology Mammogram: $0 in-network / 40% out-of-network, for more information see Evidence of Coverage |
| Home health care | $0 in-network / 40% out-of-network |
| Mental health inpatient care | In-Network: Psychiatric Hospital Services: $370.00 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/ 40% out-of-network, for more information see Evidence of Coverage Psychiatric Services - Group Sessions: $40 in-network/ Psychiatric Services - Individual Sessions: $40 in-network/ 40% out-of-network, for more information see Evidence of Coverage |
| Outpatient services/surgery | Ambulatory Surgical Center: $150 in-network / ASC Screening Colonoscopy Polyp Removal and Post-FIT: $0 in-network / 40% 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 |
| Podiatry services | Out-of-Network: Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 40% |
| Skilled Nursing Facility (SNF) care | $0 per day, days 1-20; $196 per day, days 21-100 in-network/ 40% per stay out-of-network, for more information see Evidence of Coverage |
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 Dental Coverage This benefit covers most dental treatments with the exception of cosmetic services. Preventive dental services: • Oral exams: $0 copay • Cleanings: $0 copay • Fluoride treatments: $0 copay • Dental x-rays: $0 copay Comprehensive dental services: • Non-routine services: $0 copay • Diagnostic services: $0 copay • Restorative services: $0 copay • Endodontics: $0 copay • Periodontics: $0 copay • Extractions: $0 copay • Prosthodontics and maxillofacial services: $0 copay Out of Network Dental Coverage Preventive dental services: • 20% coinsurance Comprehensive dental services: • 20% coinsurance $1,500 maximum benefit for preventive and comprehensive dental services combined - see Evidence of Coverage. |
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: Copayment for Medicare Covered Benefits $0 Copayment for Routine Eye Exams $0 - Maximum one exam every year Eyewear: 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 Out-of-Network: Eye Exams: Coinsurance for Medicare-Covered Benefits 40% Coinsurance for Routine Eye Exams 40% Eyewear: Coinsurance for Medicare-Covered Benefits 40% Copayment for Non-Medicare covered Benefits $0 Maximum Plan Allowance for all Non-Medicare covered Eyewear $150 reimbursement every year. For more information, see the Evidence of Coverage |
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: Copayment for Medicare Covered Benefits $0 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 Hearing Aids: Copayment for Hearing Aids $0 - Maximum two hearing aids every year Out-of-Network: Coinsurance for Medicare Covered Hearing Exams 40% Coinsurance for Non-Medicare Covered Hearing Exams 40% Member must purchase hearing aids through NationsHearing $1,250 per ear every year, for more information see the Evidence of Coverage |
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 | $0 copay for all preventive services covered under Original Medicare at zero cost sharing |
Prescription Drug Costs and Coverage
The Aetna Medicare Platinum Plan (PPO) offers prescription drug coverage, with an annual drug deductible of $175.00 (excludes Tiers 1 and 2)
Coverage & Cost | |
|---|---|
| Coverage | Cost |
| Annual drug deductible | $175.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
|
| Annual drug deductible | $175.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
|
| Annual drug deductible | $175.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
|
When reviewing Arizona 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 Arizona 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 |
Arizona Counties Served
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.