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Aetna Medicare Choice (PPO) - H5521-027-000
$85.00
Monthly Premium
Aetna Medicare Choice (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5521-027-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$85.00
Monthly Premium
Virginia 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 Virginia 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.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $85.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $590.00 |
| Out-of-pocket maximum | $6,750.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,000.00 |
| Primary care doctor visit | $0 in-network $10 out-of-network |
| Specialty doctor visit | In-Network $50 Out-of-Network $60 |
| Inpatient hospital care | $374 per day, days 1-8; $0 per day, days 9-90 in-network $474 per day, days 1-8; $0 per day, days 9-90 out-of-network |
| Urgent care | Urgent Care: Copayment for Urgent Care $40 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $125 Maximum Plan Benefit of $250,000 |
| Emergency room visit | $125 If you are admitted to the hospital within 0 hours your cost share may be waived |
| Ambulance transportation | $275 in-network $275 out-of-network |
Health Care Services and Medical Supplies
Aetna Medicare Choice (PPO) covers a range of additional benefits. Learn more about Aetna Medicare Choice (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | Out-of-Network: Medicare Covered Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 20% |
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network 0% for OneTouch/LifeScan diabetic supplies 20% for other covered diabetic supplies Out-of-Network 0% for OneTouch/LifeScan diabetic supplies 20% for other covered diabetic supplies |
| Durable medical equipment (DME) | In-Network 0% for continuous glucose monitors 20% for all other Medicare-covered DME items Out-of-Network 20% |
| Diagnostic tests, lab and radiology services, and X-rays | Lab Services: In-Network $0 Out-of-Network 20% 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 physician in their office $100 for services performed by a provider other than your primary care physician Out-of-Network 20% Imaging: Xray: $0 for services provided by your primary care physician in their office in-network; $50 for services performed by a provider other than your primary care physician in-network CT Scans: $0 for services provided by your primary care physician in their office in-network; $300 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; $300 for services performed by a provider other than your primary care physician in-network Diagnostic Radiology Mammogram: $0 in-network 20% out-of-network |
| Home health care | $0 in-network 20% out-of-network |
| 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 | In-Network $45 for Mental Health - Group Sessions $45 for Mental Health - Individual Sessions $45 for Psychiatric Services - Group Sessions $45 for Psychiatric Services - Individual Sessions 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: In-Network $0 for preventive and diagnostic colonoscopy $274 all other ambulatory surgical center services Out-of-Network $374 |
| 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 | $45 quarterly benefit amount (allowance) to purchase approved over-the-counter (OTC) health and wellness products. Approved items can be purchased online, in store, or by phone. Unused benefit amounts do not rollover. |
| Podiatry services | Out-of-Network: Medicare Covered Podiatry Services: Copayment for Medicare Covered Podiatry Services $60 |
| Skilled Nursing Facility (SNF) care | $10 per day, days 1-20; $180 per day, days 21-100 in-network 50% per stay out-of-network |
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: 50% for oral exams 50% for cleanings 50% for fluoride treatments 50% for x-rays 50% for other diagnostic dental services 50% for other preventive dental services Comprehensive dental services: 50% for restorative services 50% for endodontic services 50% for periodontic services 50% for removeable prosthodontics 50% for fixed prosthodontics 50% for oral and maxillofacial surgery 50% for adjunctive services $1,000 benefit amount (allowance) every year in and out-of-network for covered preventive and comprehensive dental services. ADA recognized dental services are covered up to the benefit amount excluding implants and 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 Diabetic eye exams $50 for all other Medicare-covered eye exams $0 for non-Medicare covered eye exams (Maximum one non-Medicare covered eye exam every year in or out-of-network) 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: $60 for Medicare-covered eye exams $60 for non-Medicare covered eye exams (Maximum one non-Medicare covered eye exam every year in or out-of-network) 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 $200 benefit amount (allowance) every year 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: $50 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 $500 benefit amount (allowance) per ear, every year for hearing aids (Maximum two hearing aids every year) Out-of-Network: Hearing Exams: $60 for Medicare-covered hearing exams $60 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 | In-Network $0 copay for all preventive services covered under Original Medicare Out-of-Network 0% for the pneumonia, influenza, Hepatitis B, and Covid-19 vaccines 50% for all other preventive services covered under Original Medicare |
Prescription Drug Costs and Coverage
The Aetna Medicare Choice (PPO) offers prescription drug coverage, with an annual drug deductible of $590.00 (excludes Tiers 1 and 2)
Coverage & Cost | |
|---|---|
| Coverage | Cost |
| Annual drug deductible | $590.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
|
| Annual drug deductible | $590.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
|
| Annual drug deductible | $590.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
|
When reviewing Virginia 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 Virginia 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 |
Virginia Counties Served
- Alexandria City
- Amelia
- Arlington
- Augusta
- Buckingham
- Caroline
- Charles City
- Chesterfield
- Clarke
- Colonial Heights City
- Cumberland
- Dinwiddie
- Emporia City
- Fairfax
- Fairfax City
- Falls Church City
- Fauquier
- Frederick
- Fredericksburg City
- Goochland
- Greensville
- Hanover
- Henrico
- Hopewell City
- King William
- Loudoun
- Manassas City
- Manassas Park City
- New Kent
- Nottoway
- Page
- Petersburg City
- Powhatan
- Prince George
- Prince William
- Rappahannock
- Richmond City
- Spotsylvania
- Stafford
- Staunton City
- Warren
- Waynesboro City
- Winchester City
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.