Aetna Medicare Premier Plan (PPO) H5521-249-000 2023 Plan Details and Costs

South Carolina 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 South Carolina Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.

Aetna Medicare Advantage Plans in South Carolina

This Aetna Medicare Advantage prescription drug plan has a small footprint – available in only 10 counties in South Carolina – but offers big benefits.

Dental, vision, hearing and prescription drug coverage are all included, as are all Medicare Part A and Part B benefits (often known together as Original Medicare).

There is a $0 monthly premium for this four-star plan, and a $150 monthly deductible is typically required before your medical insurance benefits kick in.

Basic Costs and Coverage

Coverage	Details
Monthly plan premium	$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible	$150.00
Out-of-pocket maximum	$6,700.00
Initial drug coverage limit	$0.00
Catastrophic drug coverage limit	$7,400.00
Primary care doctor visit	$0 in-network / $55 out-of-network
Specialty doctor visit	$35 in-network / $60 out-of-network
Inpatient hospital care	$380 per day, days 1-5; $0 per day, days 6-90 in-network / 50% per stay out-of-network
Urgent care	Urgent Care: Copayment for Urgent Care $0.00 to $35.00 Minimum copayment applies to urgently needed services provided in a PCP office. Maximum copayment applies to urgently needed services provided in an urgent care facility or location other than PCP. Worldwide Coverage: Copayment for Worldwide Urgent Coverage $90.00 Maximum Plan Benefit of $250000.00
Emergency room visit	$90 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	$250 in-network / $250 out-of-network

Health Care Services and Medical Supplies

Aetna Medicare Premier Plan (PPO) covers a range of additional benefits. Learn more about Aetna Medicare Premier 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 50%
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 / 30% out-of-network
Diagnostic tests, lab and radiology services, and X-rays	Lab Services: Lab Services: $0 in-network/ 50% out-of-network, for more information see Evidence of Coverage Diagnostic Procedures: Diagnostic Procedures/Tests: $0 for services provided by your primary care physician in their office in-network; $75 for services performed by a provider other than your primary care physician/ 50% out-of-network, for more information see Evidence of Coverage Imaging: Xray: $14 in-network / CT Scans: $0 for services provided by your primary care physician in their office in-network; $120 for services performed by a provider other than your primary care physician in-network / Diagnostic Radiology other than CT Scans: $0 for services provided by your primary care physician in their office in-network; $120 for services performed by a provider other than your primary care physician 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: $380.00 per day for days 1 to 4 $0.00 per day for days 5 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: $300 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	Out-of-Network: Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual or Group Sessions 50%
Over-the-counter items	Not Covered
Podiatry services	In-Network: Podiatry Services: 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

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: Copayment for Oral Exams $0 Copayment for Dental X-Rays $0 Copayment for Prophylaxis (Cleaning) $0 Copayment for Fluoride Treatment $0 Comprehensive Dental: Copayment for Non-routine Services $0 Copayment for Diagnostic Services $0 Copayment for Restorative Services $0 Out-Of-Network: Copayment for Preventive Dental $0 Non-Medicare Covered Comprehensive Dental $0 Frequency limitations may apply. See the Schedule of Benefits in your Evidence of Coverage. $2,250 maximum benefit for preventive and comprehensive dental services combined - see Evidence of Coverage.

Coverage

Details

Dental care

In-Network:

Preventive Dental:

Copayment for Oral Exams $0

Copayment for Dental X-Rays $0

Copayment for Prophylaxis (Cleaning) $0

Copayment for Fluoride Treatment $0

Comprehensive Dental:

Copayment for Non-routine Services $0

Copayment for Diagnostic Services $0

Copayment for Restorative Services $0

Out-Of-Network:

Copayment for Preventive Dental $0

Non-Medicare Covered Comprehensive Dental $0

Frequency limitations may apply. See the Schedule of Benefits in your
Evidence of Coverage.

$2,250 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 benefits	In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0-$35 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: Copayment for Medicare-Covered Benefits $60 Copayment for Routine Eye Exams $60 Eyewear: Coinsurance for Medicare-Covered Benefits 50% Copayment for Non-Medicare covered Benefits $0 Maximum Plan Allowance for all Non-Medicare covered Eyewear $105 reimbursement every year. For more information, see the Evidence of Coverage

Coverage

Details

Vision benefits

In-Network:

Eye Exams:

Copayment for Medicare Covered Benefits $0-$35

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:

Copayment for Medicare-Covered Benefits $60

Copayment for Routine Eye Exams $60

Eyewear:

Coinsurance for Medicare-Covered Benefits 50%

Copayment for Non-Medicare covered Benefits $0

Maximum Plan Allowance for all Non-Medicare covered Eyewear $105
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 benefits	In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $35 Copayment for Routine hearing Exams $0 - Maximum one exam every year Out-of-Network: Copayment for Medicare Covered Hearing Exams $60 Copayment for Non-Medicare Covered Hearing Exams $60

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 Premier Plan (PPO) offers prescription drug coverage, with an annual drug deductible of $150.00 (excludes Tiers 1, 2 and 3)

Coverage	Cost
Coverage & Cost
Annual drug deductible	$150.00 (excludes Tiers 1, 2 and 3)
Tier 1	Preferred retail $0.00 Standard retail $15.00 Preferred mail order $0.00 Standard mail order $15.00
Tier 2	Preferred retail $10.00 Standard retail $20.00 Preferred mail order $10.00 Standard mail order $20.00
Tier 3	Preferred retail $47.00 Standard retail $47.00 Preferred mail order $47.00 Standard mail order $47.00
Annual drug deductible	$150.00 (excludes Tiers 1, 2 and 3)
Tier 1	Preferred retail $0.00 Standard retail $30.00 Preferred mail order $0.00 Standard mail order $30.00
Tier 2	Preferred retail $20.00 Standard retail $40.00 Preferred mail order $20.00 Standard mail order $40.00
Tier 3	Preferred retail $94.00 Standard retail $94.00 Preferred mail order $94.00 Standard mail order $94.00
Annual drug deductible	$150.00 (excludes Tiers 1, 2 and 3)
Tier 1	Preferred retail $0.00 Standard retail $45.00 Preferred mail order $0.00 Standard mail order $45.00
Tier 2	Preferred retail $20.00 Standard retail $60.00 Preferred mail order $20.00 Standard mail order $60.00
Tier 3	Preferred retail $141.00 Standard retail $141.00 Preferred mail order $141.00 Standard mail order $141.00

When reviewing South Carolina 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 South Carolina 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.

Plan Documents

Links to plan documents	Summary of benefits Evidence of coverage Star ratings

Links to plan documents

South Carolina Counties Served

Chesterfield Darlington Dillon Florence Georgetown Horry Lee Marion Marlboro Williamsburg

Enrolling in Aetna Medicare Advantage Plans in South Carolina

South Carolina Medicare beneficiaries 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.