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Aetna Medicare Deluxe Plan (PPO) - H5522-023-000
$0.00
Monthly Premium
Aetna Medicare Deluxe Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5522-023-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
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.
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 | $0.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $0.00 |
| Out-of-pocket maximum | $7,550.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $8,000.00 |
| Primary care doctor visit | $0 in-network | 40% out-of-network |
| Specialty doctor visit | $35 in-network | 40% out-of-network |
| Inpatient hospital care | $350 per stay in-network | 40% per stay out-of-network |
| Urgent care | Urgent Care: Copayment for Urgent Care $50.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $100.00 |
| Emergency room visit | $100 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 | $275 in-network | $275 out-of-network |
Health Care Services and Medical Supplies
Aetna Medicare Deluxe Plan (PPO) covers a range of additional benefits. Learn more about Aetna Medicare Deluxe Plan (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 40% |
| Diabetes supplies, training, nutrition therapy and monitoring | 0% - 20% Higher cost-share applies to non-OneTouch/LifeScan diabetic supplies. |
| Durable medical equipment (DME) | 0% - 20% for each Medicare-covered durable medical equipment item | 0% for continuous glucose meters | 20% for all other Medicare-covered DME items | 20% out-of-network |
| Diagnostic tests, lab and radiology services, and X-rays | Lab Services: Lab Services: $0 in-network| 40% out-of-network, for more information see Evidence of Coverage Diagnostic Procedures: Diagnostic Procedures/Tests: $0 in-network| 40% out-of-network, for more information see Evidence of Coverage Imaging: Xray: $15 in-network | CT Scans: $0 for services provided by your primary care physician in their office in-network; $295 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; $295 for services performed by a provider other than your primary care physician in-network | Diagnostic Radiology Mammogram: $0 in-network | 40% 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 40% |
| Mental health outpatient care | Mental Health - Group Sessions: $35 in-network| Mental Health - Individual Sessions: $35 in-network| 45% out-of-network, for more information see Evidence of Coverage |Psychiatric Services - Group Sessions: $35 in-network| Psychiatric Services - Individual Sessions: $35 in-network| 45% out-of-network, for more information see Evidence of Coverage |
| Outpatient services/surgery | Ambulatory Surgical Center: $0 in network for preventive and diagnostic colonoscopy | $250 All other in network ASC services | 40% 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:|$135 quarterly amount (allowance) to purchase approved OTC health and wellness products like first aid supplies, cold and allergy medicine, pain relievers and more. Approved items can be purchased online, in store, or by phone. |Be sure to use the full benefit amount quarterly, because any unused amount will not rollover.|Nicotine Replacement Therapy(NRT) offered as a Part C OTC benefit.|Seasonal over-the-counter (OTC) kit of preselected OTC items mailed twice a year, 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; $203 per day, days 21-100 in-network| 40% 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|For covered services: ADA recognized dental services are covered excluding only cosmetic services, those considered medical in nature, and administrative changes.|Preventive dental services: |Oral exams: $0 copay |Cleanings: $0 copay |Fluoride treatment: $0 copay |Bitewing x-rays: $0 copay |Comprehensive dental services:|Non-routine services: $0 copay |Diagnostic services: $0 copay |Restorative services: $0 copay |Endodontics: $0 copay |Periodontics: $0 copay |Extractions: $0 copay |Prosthodontics and maxillofacial services: $0 copay |Out Of Network Dental Coverage|Preventive dental services:| $0 copay |Comprehensive dental services:| $0 copay |$2,500 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 care | In-Network:|Eye Exams:|Copayment for Medicare Covered Benefits $0-$35|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 40%|Coinsurance for Routine Eye Exams 40%|Eyewear:|Coinsurance for Medicare-Covered Benefits 40%|Copayment for Non-Medicare covered Benefits $0|Maximum Plan Allowance for all Non-Medicare covered Eyewear $345 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 care | In-Network:|Hearing Exams:|Copayment for Medicare Covered Benefits $35|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 40%|Coinsurance for Non-Medicare Covered Hearing Exams 40% |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 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Plan Documents
| Links to plan documents |
Pennsylvania Counties Served
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.