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Aetna Medicare Prime Chronic Care (HMO C-SNP) - H3959-077-000

4.5 out of 5 stars* for plan year 2025

$0.00

Monthly Premium

Aetna Medicare Prime Chronic Care (HMO C-SNP) is a HMO C-SNP Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.

Plan ID: H3959-077-000

* 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.

Basic Costs and Coverage

CoverageDetails
Monthly plan premium$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$300.00
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
Specialty doctor visitIn-Network|$0 for certain physician specialist visits including: Cardiologists, Endocrinologists, Nephrologists, and Pulmonologists|$35 for all other physician specialist visits
Inpatient hospital care$485 per day, days 1-5; $0 per day, days 6-90
Urgent care
Urgent Care:
Copayment for Urgent Care $55

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $120
Maximum Plan Benefit of $50,000
Emergency room visit$120 If you are admitted to the hospital within 24 hours your cost share may be waived
Ambulance transportation$345

Health Care Services and Medical Supplies

Aetna Medicare Prime Chronic Care (HMO C-SNP) covers a range of additional benefits. Learn more about Aetna Medicare Prime Chronic Care (HMO C-SNP) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

CoverageDetails
Chiropractic servicesIn-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $20
Diabetes supplies, training, nutrition therapy and monitoringIn-Network|$0
Durable medical equipment (DME)In-Network|0% for continuous glucose monitors|20% for all other Medicare-covered DME items
Diagnostic tests, lab and radiology services, and X-raysLab Services: In-Network|$0
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
Imaging: Xray: $20 in-network|CT Scans: $0 for services provided by your primary care physician in their office in-network; $195 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; $195 for services performed by a provider other than your primary care physician in-network|Diagnostic Radiology Mammogram: $0 in-network
Home health care$0
Mental health inpatient careIn-Network:

Psychiatric Hospital Services:
$455 per day for days 1 to 5
$0 per day for days 6 to 90
Prior Authorization Required for Psychiatric Hospital Services
Mental health outpatient careIn-Network|$35 for Mental Health - Group Sessions|$35 for Mental Health - Individual Sessions|$35 for Psychiatric Services - Group Sessions|$35 for Psychiatric Services - Individual Sessions
Outpatient services/surgeryAmbulatory Surgical Center: In-Network|$0 for preventive and diagnostic colonoscopy|$300 all other ambulatory surgical center services
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $35
Copayment for Medicare-covered Group Sessions $35
Prior Authorization Required for Outpatient Substance Abuse Services
Over-the-counter itemsBy qualifying for enrollment in this plan, members receive coverage for approved over-the-counter (OTC) products under the Extra Supports Wallet on the Extra Benefits Card.
Podiatry servicesIn-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $0
Copayment for Routine Foot Care $0
  • Maximum 4 visits every year
Skilled Nursing Facility (SNF) care$10 per day, days 1-20; $214 per day, days 21-100 in-network

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Dental careIn-Network||Preventive dental services:|$0 for oral exams|$0 for cleanings|$0 for x-rays||Comprehensive dental services:|20%-50% for restorative services|20% for endodontic services|20%-50% for periodontic services|50% for removeable prosthodontics|50% for fixed prosthodontics|20% - 50% for oral and maxillofacial surgery|20% - 50% for adjunctive services|$1,500 benefit amount (allowance) every year for covered comprehensive dental services. Frequencies and medical necessity requirements vary by covered dental service. Covered preventive dental services do not count towards your annual benefit amount. See EOC for additional details on exclusions and limitations.

Vision Benefits

The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage

CoverageDetails
Vision careIn-Network||Eye Exams:|$0 for non-Medicare covered eye exams|(Maximum one non-Medicare covered eye exam every year)||Eyewear:|$0 for Contacts|$0 for Eyeglasses|$0 for Eyeglass Frames|$0 for Eyeglass Lenses|$0 for Upgrades||$375 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.

CoverageDetails
Hearing careIn-Network||Hearing Exams:|$35 for Medicare-covered hearing exams|$0 for non-Medicare covered hearing exams|(Maximum one non-Medicare covered hearing exam every year)|$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)

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.

CoverageDetails
Preventive services and health/wellness education programsIn-Network|$0 copay for all preventive services covered under Original Medicare

Prescription Drug Costs and Coverage

The Aetna Medicare Prime Chronic Care (HMO C-SNP) offers prescription drug coverage, with an annual drug deductible of $300.00 (excludes Tiers 1 and 2)

Coverage & Cost
Coverage
Cost
Annual drug deductible$300.00 (excludes Tiers 1 and 2)
Tier 1
  • Preferred retail $0.00
  • Standard retail $2.00
  • Preferred mail order $0.00
  • Standard mail order $2.00
Tier 2
  • Preferred retail $5.00
  • Standard retail $12.00
  • Preferred mail order $5.00
  • Standard mail order $12.00
Annual drug deductible$300.00 (excludes Tiers 1 and 2)
Tier 1
  • Preferred retail $0.00
  • Standard retail $4.00
  • Preferred mail order $0.00
  • Standard mail order $4.00
Tier 2
  • Preferred retail $10.00
  • Standard retail $24.00
  • Preferred mail order $10.00
  • Standard mail order $24.00
Annual drug deductible$300.00 (excludes Tiers 1 and 2)
Tier 1
  • Preferred retail $0.00
  • Standard retail $6.00
  • Preferred mail order $0.00
  • Standard mail order $6.00
Tier 2
  • Preferred retail $15.00
  • Standard retail $36.00
  • Preferred mail order $10.00
  • Standard mail order $36.00

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.

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