Aetna Medicare Premier (PPO)

3.5 out of 5 stars* for plan year 2023

$44.00 Monthly Premium

Aetna Medicare Premier (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.

Plan ID: H1608-035-000

$44.00 Monthly Premium

Missouri 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 Missouri 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	$44.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible	$150.00
Out-of-pocket maximum	$7,550.00
Initial drug coverage limit	$0.00
Catastrophic drug coverage limit	$7,400.00
Primary care doctor visit	$10 in-network / 40% out-of-network
Specialty doctor visit	$50 in-network / 40% out-of-network
Inpatient hospital care	$315 per day, days 1-6; $0 per day, days 7-90 in-network / 40% per stay out-of-network
Urgent care	Urgent Care: Copayment for Urgent Care $50.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $95.00
Emergency room visit	$95 If you are admitted to the hospital within 24 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 Premier (PPO) covers a range of additional benefits. Learn more about Aetna Medicare Premier (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 / 25% 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: $50 in-network/ 40% out-of-network, for more information see Evidence of Coverage Imaging: Xray: $0 in-network / CT Scans: $110 in-network / Diagnostic Radiology other than CT Scans: $110 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: $310.00 per day for days 1 to 6 $0.00 per day for days 7 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: $275 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	Out-of-Network: Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual or Group Sessions 40%
Podiatry services	Out-of-Network: Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 40% Podiatry Services: Coinsurance for Non-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	$300 reimbursement every year for preventive and comprehensive services, for more information see the 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	$100 every year, 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	$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 Premier (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 $0.00 Standard retail $20.00 Preferred mail order $0.00 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 $0.00 Standard retail $40.00 Preferred mail order $0.00 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 $0.00 Standard retail $60.00 Preferred mail order $0.00 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 Missouri 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 Missouri 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 Star ratings

Links to plan documents

Missouri Counties Served

Lewis Marion Monroe Ralls

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