Aetna Medicare Value Plan (PPO)
Aetna Medicare Value Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5521-281-000
Tennessee 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 Tennessee 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 | $15.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $0.00 |
| Out-of-pocket maximum | $5,900.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $7,400.00 |
| Primary care doctor visit | $0 in-network / $0 out-of-network |
| Specialty doctor visit | $20 in-network / $20 out-of-network |
| Inpatient hospital care | $275 per day, days 1-6; $0 per day, days 7-90 in-network / $275 per day, days 1-6; $0 per day, days 7-90 out-of-network |
| Urgent care | Urgent Care: Copayment for Urgent Care $0.00 to $20.00 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 Value Plan (PPO) covers a range of additional benefits. Learn more about Aetna Medicare Value Plan (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 $20.00 Prior Authorization 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% in-network / 20% out-of-network |
| Diagnostic tests, lab and radiology services, and X-rays | Lab Services: Lab Services: $0 in-network/ 20% 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/ 20% 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 / 20% out-of-network, for more information see Evidence of Coverage |
| Home health care | $0 in-network / 20% out-of-network |
| Mental health inpatient care | In-Network: Psychiatric Hospital Services: $324.00 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/ 20% out-of-network, for more information see Evidence of Coverage Psychiatric Services - Group Sessions: $40 in-network/ Psychiatric Services - Individual Sessions: $40 in-network/ 20% 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 / $275 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 20% |
| Over-the-counter items | $150 quarterly OTC allowance, for more information see Evidence of Coverage |
| Podiatry services | Out-of-Network: Podiatry Services: Copayment for Medicare Covered Podiatry Services $20.00 |
| Skilled Nursing Facility (SNF) care | $0 per day, days 1-20; $196 per day, days 21-100 in-network/ 20% 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 | $2,200 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 | $100 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 | Not Covered |
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 |
When reviewing Tennessee 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 Tennessee 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 |
