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Aetna Medicare Elite (PPO) - H5521-371-000
$24.00
Monthly Premium
Aetna Medicare Elite (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5521-371-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$24.00
Monthly Premium
California 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 California 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 | $24.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $590.00 |
| Out-of-pocket maximum | $5,500.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,000.00 |
| Primary care doctor visit | $0 in-network|$25 out-of-network |
| Specialty doctor visit | In-Network|$0 for services provided in a nursing home|$25 for services provided outside a nursing home||Out-of-Network|$65 |
| Inpatient hospital care | $325 per day, days 1-4; $0 per day, days 5-90 in-network|45% per stay out-of-network |
| Urgent care | Urgent Care: Copayment for Urgent Care $40 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $125 |
| Emergency room visit | $125 If you are admitted to the hospital within 0 hours your cost share may be waived |
| Ambulance transportation | $285 in-network|$285 out-of-network |
Health Care Services and Medical Supplies
Aetna Medicare Elite (PPO) covers a range of additional benefits. Learn more about Aetna Medicare Elite (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 |
| 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|45% |
| Diagnostic tests, lab and radiology services, and X-rays | Lab Services: In-Network|$0 ||Out-of-Network|$65 Diagnostic Procedures: In-Network|$0||Out-of-Network|45% Imaging: Xray: $0 in-network|CT Scans: $200 in-network|Diagnostic Radiology other than CT Scans: $200 in-network|Diagnostic Radiology Mammogram: $0 in-network|45% out-of-network |
| Home health care | $0 in-network|45% out-of-network |
| Mental health inpatient care | In-Network: Psychiatric Hospital Services: $325 per day for days 1 to 4 $0 per day for days 5 to 90 Prior Authorization Required for Psychiatric Hospital Services |
| Mental health outpatient care | In-Network|$40 for Mental Health - Group Sessions|$40 for Mental Health - Individual Sessions|$40 for Psychiatric Services - Group Sessions|$40 for Psychiatric Services - Individual Sessions||Out-of-Network|45% for Mental Health Services- Group Sessions|45% for Mental Health Services - Individual Sessions|45% for Psychiatric Services - Group Sessions|45% for Psychiatric Services - Individual Sessions |
| Outpatient services/surgery | Ambulatory Surgical Center: In-Network|$0 for preventive and diagnostic colonoscopy|$295 all other ambulatory surgical center services||Out-of-Network|45% |
| 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 | $30 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: Coinsurance for Medicare Covered Podiatry Services 45% |
| Skilled Nursing Facility (SNF) care | $10 per day, days 1-20; $130 per day, days 21-100 in-network|45% 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. Medical necessity requirements vary by covered dental service.||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 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:|45% for Medicare-covered eye exams|45% for non-Medicare covered eye exams|(Maximum one non-Medicare covered eye exam every year in or out-of-network)||Eyewear:|45% 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||$75 benefit amount (allowance) reimbursement 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:|$0 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|$1,250 benefit amount (allowance) per ear, every year for hearing aids|(Maximum two hearing aids every year)||Out-of-Network:||Hearing Exams:|45% for Medicare-covered hearing exams|45% 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|45% for all other preventive services covered under Original Medicare |
Prescription Drug Costs and Coverage
The Aetna Medicare Elite (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 California 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 California 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 |
California Counties Served
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