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Aetna Medicare Signature Extra (PPO) - H5521-170-000
$0.00
Monthly Premium
Aetna Medicare Signature Extra (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5521-170-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
North 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 additional benefits Original Medicare doesn’t cover.
Learn more about North Carolina Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Enrollment may be limited to certain times of the year. See why you may be able to enroll today.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $0.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $500.00 |
| Out-of-pocket maximum | $5,900.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,100.00 |
| Primary care doctor visit | Out-of-Network|$10 |
| Specialty doctor visit | Out-of-Network|$40 |
| Inpatient hospital care | In-Network|$382 per day, days 1-8; $0 per day, days 9-90 |
| Urgent care | Urgent Care: Copayment for Urgent Care $20 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $130 Maximum Plan Benefit of $250,000 |
| Emergency room visit | $130 If you are admitted to the hospital within 24 hours your cost share may be waived |
| Ambulance transportation | Out-of-Network|$275 |
Health Care Services and Medical Supplies
Aetna Medicare Signature Extra (PPO) covers a range of additional benefits. Learn more about Aetna Medicare Signature Extra (PPO) 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 $15 |
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network|0% for Roche/Accu-Chek and TRUE/Trividia diabetic supplies|20% for other covered diabetic supplies |
| Durable medical equipment (DME) | Out-of-Network|20% |
| Diagnostic tests, lab and radiology services, and X-rays | Lab Services: In-Network|$0 for Hemoglobin A1C tests|$0 for services provided by your primary care provider in their office|$25 for services performed by a provider other than your primary care provider Diagnostic Procedures: In-Network|$0 for certain Medicare-covered diagnostic tests and services including Retinal fundus, Spirometry, Peripheral arterial disease (PAD)||$0 for services provided by your primary care provider in their office|$200 for services performed by a provider other than your primary care provider Imaging: In-Network|Xray: $0 for services provided by your primary care provider in their office; $14 for services performed by a provider other than your primary care provider|CT Scans: $0 for services provided by your primary care provider in their office; $300 for services performed by a provider other than your primary care provider|Diagnostic Radiology other than CT Scans: $0 for services provided by your primary care provider in their office; $300 for services performed by a provider other than your primary care provider|Diagnostic Radiology Mammogram: $0 |
| Home health care | In-Network|$0 |
| Mental health inpatient care | In-Network: Psychiatric Hospital Services: $286 per day for days 1 to 8 $0 per day for days 9 to 90 Prior Authorization Required for Psychiatric Hospital Services |
| Mental health outpatient care | Out-of-Network|20% for Mental Health Services- Group Sessions|20% for Mental Health Services - Individual Sessions|20% for Psychiatric Services - Group Sessions|20% for Psychiatric Services - Individual Sessions |
| Outpatient services/surgery | Ambulatory Surgical Center: Out-of-Network|$432 |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $40 Copayment for Medicare-covered Group Sessions $40 Prior Authorization Required for Outpatient Substance Abuse Services |
| Over-the-counter items | CVS Over-the-Counter (OTC) Wallet with a $30 quarterly benefit amount (allowance) on the Extra Benefits Card to help pay for approved OTC health and wellness products like first aid supplies, cold and allergy medicine, pain relievers, and more. Approved products can be purchased in-store at participating CVS retail locations (excluding locations inside other stores), and online or by phone through CVS OTC Health Solutions. |
| Podiatry services | Out-of-Network: Podiatry Services: Copayment for Medicare Covered Podiatry Services $40 |
| Skilled Nursing Facility (SNF) care | Out-of-Network|20% per stay |
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 services:|$0 for oral exams|$0 for cleanings|$0 for x-rays||Comprehensive dental services:|20%-50% for restorative services|20% for endodontic services|20%-50% for periodontic services|50% for removeable prosthodontics|50% for fixed prosthodontics|20% - 50% for oral and maxillofacial surgery|20% - 50% for adjunctive services |
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 | Out-of-Network||Eye Exams:|$40 for Medicare-covered eye exams|$0 for non-Medicare covered eye exams|Maximum one non-Medicare covered routine eye exam every calendar year in or out-of-network (out of network covered up to $50)||Eyewear:|20% for Medicare-covered prescription eyewear|$0 for Contacts|$0 for Eyeglass Frames|$0 for Eyeglass Lenses|$0 for Eyeglass Lenses and Frames|$0 for Upgrades||$200 annual benefit amount (allowance) for non-Medicare covered prescription eyewear. |
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:|$30 for Medicare-covered hearing exams|$0 for non-Medicare covered hearing exams|(Maximum one non-Medicare covered hearing exam every year in or out-of-network)|$0 for fitting/evaluation for hearing aids|(Maximum one hearing aid fitting/evaluation every year)||Hearing Aids:|$0 for hearing aids|$1,250 benefit amount (allowance) per ear, every year for hearing aids|(Maximum two hearing aids every year) |
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 | In-Network|$0 for all preventive services covered under Original Medicare |
Prescription Drug Costs and Coverage
The Aetna Medicare Signature Extra (PPO) offers prescription drug coverage, with an annual drug deductible of $500.00 (excludes Tiers 1 and 2)
Coverage & Cost | |
|---|---|
| Coverage | Cost |
| Annual drug deductible | $500.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
|
| Annual drug deductible | $500.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
|
| Annual drug deductible | $500.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
|
When reviewing North 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 North Carolina 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 |
North Carolina Counties Served
We offer plans from Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Healthspring, Wellcare, or Kaiser Permanente.
Enrollment may be limited to certain times of the year. See why you may be able to enroll today.