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Allina Health Aetna Medicare Grand Extra (PPO) - H3219-004-000
$154.00
Monthly Premium
Allina Health Aetna Medicare Grand Extra (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H3219-004-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$154.00
Monthly Premium
Minnesota 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 Minnesota 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 | $154.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $0.00 |
| Out-of-pocket maximum | $3,300.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,100.00 |
| Primary care doctor visit | Out-of-Network|50% |
| Specialty doctor visit | In-Network $15 Out-of-Network 50% |
| Inpatient hospital care | Out-of-Network|50% per stay |
| Urgent care | Urgent Care: Copayment for Urgent Care $15 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $150 Maximum Plan Benefit of $250,000 |
| Emergency room visit | $150 If you are admitted to the hospital within 24 hours your cost share may be waived |
| Ambulance transportation | Out-of-Network|$250 |
Health Care Services and Medical Supplies
Allina Health Aetna Medicare Grand Extra (PPO) covers a range of additional benefits. Learn more about Allina Health Aetna Medicare Grand 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 $20 Copayment for Routine Care $20
|
| Diabetes supplies, training, nutrition therapy and monitoring | Out-of-Network|0% for Roche/Accu-Chek and TRUE/Trividia diabetic supplies|20% for other covered diabetic supplies |
| Durable medical equipment (DME) | Out-of-Network|50% |
| Diagnostic tests, lab and radiology services, and X-rays | Lab Services: In-Network $0 Out-of-Network 50% Diagnostic Procedures: In-Network $0 for certain Medicare-covered diagnostic tests and services including Retinal fundus, Spirometry, Peripheral arterial disease (PAD) $20 for other diagnostic procedures and tests Out-of-Network 50% Imaging: In-Network Xray: $15 CT Scans: $50 Diagnostic Radiology other than CT Scans: $50 Diagnostic Radiology Mammogram: $0 Out-of-Network 50% |
| Home health care | In-Network $0 Out-of-Network 50% |
| Mental health inpatient care | Out-of-Network: Psychiatric Hospital Services: Coinsurance for Psychiatric Hospital per Stay 50% |
| Mental health outpatient care | In-Network $15 for Mental Health - Group Sessions $15 for Mental Health - Individual Sessions $15 for Psychiatric Services - Group Sessions $15 for Psychiatric Services - Individual Sessions Out-of-Network 50% for Mental Health Services- Group Sessions 50% for Mental Health Services - Individual Sessions 50% for Psychiatric Services - Group Sessions 50% for Psychiatric Services - Individual Sessions |
| Outpatient services/surgery | Ambulatory Surgical Center: Out-of-Network|50% |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $15 Copayment for Medicare-covered Group Sessions $15 Prior Authorization Required for Outpatient Substance Abuse Services |
| Over-the-counter items | CVS Over-the-Counter (OTC) Wallet with a $75 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 | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $15 Copayment for Routine Foot Care $15
|
| Skilled Nursing Facility (SNF) care | Out-of-Network|50% 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 fluoride treatment $0 for x-rays $0 for other diagnostic dental services $0 for other preventive dental services Comprehensive dental services: $0 for restorative services $0 for endodontic services $0 for periodontic services $0 for removeable prosthodontics $0 for fixed prosthodontics $0 for oral and maxillofacial surgery $0 for adjunctive services Out-of-Network Preventive dental services: 20% for oral exams 20% for cleanings 20% for fluoride treatments 20% for x-rays 20% for other diagnostic dental services 20% for other preventive dental services Comprehensive dental services: 20% for restorative services 20% for endodontic services 20% for periodontic services 20% for removeable prosthodontics 20% for fixed prosthodontics 20% for oral and maxillofacial surgery 20% for adjunctive services $2,100 benefit amount (allowance) every year in and out-of-network for covered preventive and comprehensive dental services combined. Medical necessity requirements vary by covered dental service. ADA recognized dental services are covered up to the benefit amount excluding implants and implant related services, orthodontics, cosmetic services, those considered medical in nature, and administrative charges. See EOC for a full list of exclusions. |
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 | In-Network Eye Exams: $0 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 with an EyeMed provider Eyewear: $0 for Medicare-covered prescription eyewear $0 for Contacts $0 for Eyeglasses $0 for Eyeglass Frames $0 for Eyeglass Lenses $0 for Upgrades Out-of-Network Eye Exams: 50% 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: 50% 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 $275 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: $15 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 $1,500 benefit amount (allowance) per ear, every year for hearing aids (Maximum two hearing aids every year) Out-of-Network: Hearing Exams: 50% for Medicare-covered hearing exams 50% for non-Medicare covered hearing exam every year in or out-of-network Hearing Aids: You must purchase hearing aids through NationsHearing |
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 | Out-of-Network|0% for the pneumonia, influenza, Hepatitis B, and Covid-19 vaccines|50% for all other preventive services covered under Original Medicare |
When reviewing Minnesota 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 Minnesota 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 |
Minnesota 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.