Aetna Medicare Premier Plan (HMO) H2663-034 2024 Plan Details and Costs (2024)

Aetna Medicare Premier Plan (HMO) H2663-034 2024 Plan Details and Costs (1)

Aetna Medicare Premier Plan (HMO) H2663-034 Plan Details

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Aetna Medicare Premier Plan (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H2663-034

HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied bySunFire, Inc.,a private company that creates software solutionsfor agents and brokers to compareMedicare plans. For more information, visitwww.sunfireinc.com.

Aetna Medicare Premier Plan (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H2663-034

HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied bySunFire, Inc.,a private company that creates software solutionsfor agents and brokers to compareMedicare plans. For more information, visitwww.sunfireinc.com.

Aetna Medicare Premier Plan (HMO) H2663-034 2024 Plan Details and Costs (2)

Aetna Medicare Premier Plan (HMO) H2663-034 Plan Details

Aetna Medicare Premier Plan (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H2663-034

HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied bySunFire, Inc.,a private company that creates software solutionsfor agents and brokers to compareMedicare plans. For more information, visitwww.sunfireinc.com.

$0.00

Monthly Premium

Oklahoma Counties Served

Oklahoma Canadian Logan

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $150
Out of Pocket Max In-Network: $6000
Out-of-Network: N/A
Initial Coverage Limit $5030
Catastrophic Coverage Limit $8,000
Primary Care Doctor Visit

$0

Specialty Doctor Visit

$30

Inpatient Hospital Care

$295 per day, days 1-7; $0 per day, days 8-90

Urgent Care

Copayment for Urgent Care $60.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $120.00

Emergency Room Visit

$120 If you are admitted to the hospital within 0 hours your cost share may be waived, for more information see the Evidence of Coverage

Ambulance Transportation

$250

Health Care Services and Medical Supplies

Aetna Medicare Premier Plan (HMO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services

In-Network:
Copayment for Medicare-covered Chiropractic Services $20.00
Prior Authorization Required for Chiropractic Services
Referral Required for Chiropractic Services
Prior authorization required

Diabetes Supplies, Training, Nutrition Therapy and Monitoring

0% - 20% Higher cost-share applies to non-OneTouch/LifeScan diabetic supplies.

Durable Medical Eqipment (DME)

20%

Diagnostic Tests, Lab and Radiology Services, and X-Rays

Lab Services: Lab Services: $0 in-network, for more information see Evidence of Coverage
Diagnostic Procedures: Diagnostic Procedures/Tests: $50 in-network, for more information see Evidence of Coverage
Imaging: Xray: $30 in-network | CT Scans: $295 in-network | Diagnostic Radiology other than CT Scans: $295 in-network | Diagnostic Radiology Mammogram: $0 in-network, for more information see Evidence of Coverage

Home Health Care

$0

Mental Health Inpatient Care

In-Network:

Psychiatric Hospital Services:
$275.00 per day for days 1 to 7
$0.00 per day for days 8 to 90
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required

Mental Health Outpatient Care

Mental Health:
Group Sessions: $30 in-network|
Individual Sessions: $30 in-network, for more information see Evidence of Coverage |Psychiatric Services:
Group Sessions: $30 in-network|
Individual Sessions: $30 in-network, for more information see Evidence of Coverage

Outpatient Services / Surgery

Ambulatory Surgical Center: $0 in network for preventive and diagnostic colonoscopy | $245 All other in network ASC services, for more information see Evidence of Coverage

Outpatient Substance Abuse Care

In-Network:
Copayment for Medicare-covered Individual Sessions $40.00
Copayment for Medicare-covered Group Sessions $40.00
Prior Authorization Required for Outpatient Substance Abuse Services
Prior authorization required

Over-the-counter (OTC) Items

In Network: |Over-the-counter (OTC) items:|$105 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:
Copayment for Medicare-Covered Podiatry Services $30.00
Referral Required for Podiatry Services

Skilled Nursing Facility Care

$10 per day, days 1-20
$203 per day, days 21-100 in-network, for more information see Evidence of Coverage

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care

In Network Dental Coverage |Preventive dental services:|Oral exams: $0 copay (four visits every year) |Cleanings: $0 copay (two visits every year) |Bitewing x-rays: $0 copay (one visit every year) |Comprehensive dental services:|Non-routine services: 20%-50% coinsurance (see Evidence of Coverage) |Diagnostic services: $0 copay (see Evidence of Coverage) |Restorative services: 20%-50% coinsurance (see Evidence of Coverage) |Endodontics: 20% coinsurance (see Evidence of Coverage) |Periodontics: 20%-50% coinsurance (see Evidence of Coverage) |Extractions: 20%-50% coinsurance (see Evidence of Coverage) |Prosthodontics and maxillofacial services: 50% coinsurance (see Evidence of Coverage) |$2,500 maximum benefit for comprehensive dental services - see Evidence of Coverage.

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits

In-Network:|Eye Exams:|Copayment for Medicare Covered Benefits $0|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|Maximum Plan Allowance for all Non-Medicare covered Eyewear $300 every year. See the Evidence of Coverage

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits

In-Network:|Hearing Exams:|Copayment for Medicare Covered Benefits $30|Referral Required for Hearing Exams|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)|$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 from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs

$0 copay for all preventive services covered under Original Medicare at zero cost sharing

Prescription Drug Costs and Coverage

The Aetna Medicare Premier Plan (HMO) plan offers the following prescription drug coverage, with an annual drug deductible of $150 (excludes Tiers 1 and 2) per year.

Coverage

Cost

Coverage & Cost

Annual Drug Deductible $150 (excludes Tiers 1 and 2)
Preferred Generic
  • Standard mail order $5.00
  • Preferred cost-share retail $0.00
  • Standard retail $5.00
  • Preferred cost-share mail order $0.00
Generic
  • Standard mail order $10.00
  • Preferred cost-share retail $0.00
  • Standard retail $10.00
  • Preferred cost-share mail order $0.00
Annual Drug Deductible $150 (excludes Tiers 1 and 2)
Preferred Generic
  • Standard mail order $10.00
  • Preferred cost-share retail $0.00
  • Standard retail $10.00
  • Preferred cost-share mail order $0.00
Generic
  • Standard mail order $20.00
  • Preferred cost-share retail $0.00
  • Standard retail $20.00
  • Preferred cost-share mail order $0.00
Annual Drug Deductible $150 (excludes Tiers 1 and 2)
Preferred Generic
  • Standard mail order $15.00
  • Preferred cost-share retail $0.00
  • Standard retail $15.00
  • Preferred cost-share mail order $0.00
Generic
  • Standard mail order $30.00
  • Preferred cost-share retail $0.00
  • Standard retail $30.00
  • Preferred cost-share mail order $0.00

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Aetna Medicare Premier Plan (HMO) H2663-034 2024 Plan Details and Costs (2024)

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