Aetna Medicare Value Plus (PPO)
Aetna Medicare Value Plus (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5522-021-000
Pennsylvania 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 Pennsylvania 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 | $45.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $0.00 |
| Out-of-pocket maximum | $6,700.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $7,400.00 |
| Primary care doctor visit | $5 in-network / 10% out-of-network |
| Specialty doctor visit | $40 in-network / 20% out-of-network |
| Inpatient hospital care | $475 per stay in-network / 20% 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 | $250 in-network / $250 out-of-network |
Health Care Services and Medical Supplies
Aetna Medicare Value Plus (PPO) covers a range of additional benefits. Learn more about Aetna Medicare Value Plus (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 20% |
| 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: $5 in-network/ 20% out-of-network, for more information see Evidence of Coverage Imaging: Xray: $35 in-network / CT Scans: $5 for services provided by your primary care physician in their office in-network; $275 for services performed by a provider other than your primary care physician in-network / Diagnostic Radiology other than CT Scans: $5 for services provided by your primary care physician in their office in-network; $275 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 / $0 out-of-network |
| Mental health inpatient care | Out-of-Network: Coinsurance for Psychiatric Hospital Services per Stay 20% |
| Mental health outpatient care | Mental Health - Group Sessions: $40 in-network/ Mental Health - Individual Sessions: $40 in-network/ 45% out-of-network, for more information see Evidence of Coverage Psychiatric Services - Group Sessions: $40 in-network/ Psychiatric Services - Individual Sessions: $40 in-network/ 45% out-of-network, for more information see Evidence of Coverage |
| Outpatient services/surgery | Ambulatory Surgical Center: $245 in-network / ASC Screening Colonoscopy Polyp Removal and Post-FIT: $0 in-network / 10% 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 45% |
| Over-the-counter items | In-Network: Over-The-Counter (OTC) items: Copayment for Over-The-Counter (OTC) items $0 Nicotine Replacement Therapy(NRT) offered as a Part C OTC benefit $120 quarterly OTC allowance, for more information see Evidence of Coverage |
| Podiatry services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $35.00 Copayment for Routine Foot Care $35.00
|
| 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 | In Network Dental Coverage Preventive dental services: • Oral exams: $0 copay (four exams every year) • Cleanings: $0 copay (two cleanings every calendar year) • Dental x-rays: $0 copay (one set of bitewing x-rays every calendar year) Comprehensive dental services: • Non-routine services: 20%-50% coinsurance (see Evidence of Coverage) • Diagnostic services: $0 copay (see Evidence of Coverage) • Restorative services: 20%-50% coinsurance (see Evidence of Coverage) • Endodontics: 20% coinsurance (see Evidence of Coverage) • Periodontics: 20%-50% coinsurance (see Evidence of Coverage) • Extractions: 20%-50% coinsurance (see Evidence of Coverage) • Prosthodontics and maxillofacial services: 50% coinsurance (see Evidence of Coverage) Out of Network Dental Coverage Preventive dental services: • 30% coinsurance Comprehensive dental services: • 50%-70% coinsurance (see Evidence of Coverage) $1,000 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 | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0-$40 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: Coinsurance for Medicare-Covered Benefits 20% Coinsurance for Routine Eye Exams 20% Eyewear: Coinsurance for Medicare-Covered Benefits 20% Copayment for Non-Medicare covered Benefits $0 Maximum Plan Allowance for all Non-Medicare covered Eyewear $200 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 | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $40 Copayment for Routine hearing Exams $0 - Maximum one exam every year Copayment for Fitting/Evaluation for Hearing Aid $0 - Maximum one hearing aid fitting/evaluation every year Hearing Aids: Copayment for Hearing Aids $0 - Maximum two hearing aids every year Out-of-Network: Coinsurance for Medicare Covered Hearing Exams 20% Coinsurance for Non-Medicare Covered Hearing Exams 20% Member must purchase hearing aids through NationsHearing $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 |
When reviewing Pennsylvania 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 Pennsylvania 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 |
Pennsylvania Counties Served
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.
