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Aetna Medicare Value Plus (PPO) - H5521-251-000

4.5 out of 5 stars* for plan year 2025

$19.00

Monthly Premium

Aetna Medicare Value Plus (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.

Plan ID: H5521-251-000

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$19.00

Monthly Premium

South Carolina 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 South Carolina 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$19.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$250.00
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 visitIn-Network|$0 for services provided in a nursing home|$35 for services provided outside a nursing home||Out-of-Network|$45
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 $45

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).

CoverageDetails
Chiropractic servicesIn-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $15
Diabetes supplies, training, nutrition therapy and monitoringIn-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-raysLab 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|$120 for services performed by a provider other than your primary care physician||Out-of-Network|20%
Imaging: Xray: $14 in-network|CT Scans: $0 for services provided by your primary care physician in their office in-network; $200 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; $200 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
Out-of-Network:

Psychiatric Hospital Services:
Coinsurance for Psychiatric Hospital per Stay 20%
Mental health outpatient careIn-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|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/surgeryAmbulatory Surgical Center: In-Network|$0 for preventive and diagnostic colonoscopy|$274 all other ambulatory surgical center services||Out-of-Network|$374
Outpatient substance abuse careIn-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 itemsOver-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 servicesIn-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $35
Skilled Nursing Facility (SNF) care$10 per day, days 1-20; $214 per day, days 21-100 in-network|20% 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.

CoverageDetails
Dental careIn-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

CoverageDetails
Vision careIn-Network||Eye Exams:|$0 for Diabetic eye exams|$35 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:|$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:|20% 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||$160 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.

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 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.

CoverageDetails
Preventive services and health/wellness education programsIn-Network|$0 copay for all preventive services covered under Original Medicare||Out-of-Network|$0 for all 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 $250.00 (excludes Tiers 1 and 2)

Coverage & Cost
Coverage
Cost
Annual drug deductible$250.00 (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 $10.00
  • Standard retail $12.00
  • Preferred mail order $10.00
  • Standard mail order $12.00
Annual drug deductible$250.00 (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 $20.00
  • Standard retail $24.00
  • Preferred mail order $20.00
  • Standard mail order $24.00
Annual drug deductible$250.00 (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 $30.00
  • Standard retail $36.00
  • Preferred mail order $20.00
  • Standard mail order $36.00

When reviewing South Carolina 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 South Carolina 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

South Carolina 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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