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Aetna Medicare Value Plus (PPO) - H5521-084-000
$20.00
Monthly Premium
Aetna Medicare Value Plus (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5521-084-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$20.00
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 | $20.00 |
| 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|$10 out-of-network |
| Specialty doctor visit | In-Network|$20||Out-of-Network|$30 |
| Inpatient hospital care | $374 per day, days 1-8; $0 per day, days 9-90 in-network|$374 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 Value Plus (PPO) covers a range of additional benefits. Learn more about Aetna Medicare Value Plus (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|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 | Out-of-Network: Medicare Covered Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual Sessions 20% Coinsurance for Medicare Covered Group Sessions 20% |
| Over-the-counter items | Over-the-Counter (OTC) Wallet with a $45 quarterly benefit amount (allowance) on the Extra Benefits Card to purchase approved over-the-counter (OTC) health and wellness products like first aid supplies, cold and allergy medicine, pain relievers, and more. Approved products can be purchased in-store, online, or by phone. Unused benefit amounts do not rollover. |
| Podiatry services | Out-of-Network: Medicare Covered Podiatry Services: Copayment for Medicare Covered Podiatry Services $30 |
| Skilled Nursing Facility (SNF) care | $10 per day, days 1-20; $214 per day, days 21-100 in-network|25% 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||$2,000 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|$20 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:|$30 for Medicare-covered eye exams|$30 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||$300 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:|$20 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|$2,500 benefit amount (allowance) per ear, every year for hearing aids|(Maximum two hearing aids every year)||Out-of-Network:||Hearing Exams:|$30 for Medicare-covered hearing exams|$30 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 Value Plus (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
- Accomack
- Albemarle
- Alleghany
- Amelia
- Augusta
- Bath
- Bland
- Botetourt
- Brunswick
- Buchanan
- Buckingham
- Buena Vista City
- Caroline
- Carroll
- Charles City
- Charlotte
- Charlottesville City
- Chesapeake City
- Chesterfield
- Colonial Heights City
- Covington City
- Craig
- Cumberland
- Danville City
- Dickenson
- Dinwiddie
- Emporia City
- Essex
- Floyd
- Fluvanna
- Franklin
- Franklin City
- Galax City
- Giles
- Gloucester
- Goochland
- Grayson
- Greene
- Greensville
- Halifax
- Hampton City
- Hanover
- Henrico
- Henry
- Highland
- Hopewell City
- Isle Of Wight
- James City
- Jefferson
- King And Queen
- King George
- King William
- Lancaster
- Lee
- Lexington City
- Louisa
- Lunenburg
- Madison
- Martinsville City
- Mathews
- Mecklenburg
- Middlesex
- Montgomery
- Nelson
- New Kent
- Newport News City
- Norfolk City
- Northampton
- Northumberland
- Norton City
- Nottoway
- Orange
- Patrick
- Petersburg City
- Pittsylvania
- Poquoson City
- Portsmouth City
- Powhatan
- Prince George
- Pulaski
- Radford
- Richmond
- Richmond City
- Roanoke
- Roanoke City
- Rockbridge
- Russell
- Salem
- Scott
- Shenandoah
- Smyth
- Southampton
- Staunton City
- Suffolk City
- Surry
- Sussex
- Tazewell
- Virginia Beach City
- Washington
- Waynesboro City
- Westmoreland
- Williamsburg City
- Wise
- Wythe
- York
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