Aetna Medicare Prime Plan (HMO) H4523-020-000 2023 Plan Details and Costs

Texas 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 Texas 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	$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible	$200.00
Out-of-pocket maximum	$5,000.00
Initial drug coverage limit	$0.00
Catastrophic drug coverage limit	$7,400.00
Primary care doctor visit	$0
Specialty doctor visit	$30
Inpatient hospital care	$300 per day, days 1-6; $0 per day, days 7-90
Urgent care	Urgent Care: Copayment for Urgent Care $0.00 to $60.00 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 $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	$265

Health Care Services and Medical Supplies

Aetna Medicare Prime Plan (HMO) covers a range of additional benefits. Learn more about Aetna Medicare Prime Plan (HMO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

Coverage	Details
Chiropractic services	In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $20.00 Prior Authorization Required for Chiropractic Services Referral 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)	20%
Diagnostic tests, lab and radiology services, and X-rays	Lab Services: Lab Services: $0 in-network, for more information see Evidence of Coverage Diagnostic Procedures: Diagnostic Procedures/Tests: $40 in-network, for more information see Evidence of Coverage Imaging: Xray: $30 in-network / CT Scans: $325 in-network / Diagnostic Radiology other than CT Scans: $325 in-network / Diagnostic Radiology Mammogram: $0 in-network, for more information see Evidence of Coverage
Home health care	$0
Mental health inpatient care	In-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital Services per Stay $1871.00 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, for more information see Evidence of Coverage Psychiatric Services - Group Sessions: $40 in-network/ Psychiatric Services - Individual Sessions: $40 in-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, 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	Seasonal Over-the-Counter (OTC) kit of preselected OTC items mailed twice a year and $120 quarterly OTC allowance, for more information see Evidence of Coverage
Podiatry services	In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $30.00 Referral Required for Podiatry Services
Skilled Nursing Facility (SNF) care	$10 per day, days 1-20; $196 per day, days 21-100 in-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	$3,000 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	$250 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 Prime Plan (HMO) offers prescription drug coverage, with an annual drug deductible of $200.00 (excludes Tiers 1, 2 and 3)

Coverage	Cost
Coverage & Cost
Annual drug deductible	$200.00 (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	$200.00 (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	$200.00 (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 Texas 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 Texas 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

Texas Counties Served

Bexar Comal