Aetna Medicare Assure Plan (HMO D-SNP) H3312-069
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Plan details
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Prescriptions
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Total costs
Aetna Medicare Assure Plan (HMO D-SNP) H3312-069
Monthly premium
$0.00
Plan Highlights
This D-SNP plan includes a personal care manager as well as benefits like:
- Dental, vision & hearing
- Over-the-counter (OTC) allowance
- SilverSneakers® fitness benefit
- $0 generic & brand Rx drugs
Costs
Premium
$0.00 monthly
Total est. annual cost
Based on premium and drug costs.
(Effective Jan 2022)
$0 annually
Benefits
Medical Coverage
Monthly Plan Premium
$0
Medical Deductible: In-Network
$0
Medical Deductible: Out-of-Network
$0
Maximum Out-of-Pocket (MOOP): Annual In-Network
$7,550
Primary Care Physician (PCP)
$0
Specialist
$0
Additional Telehealth Services
PCP: $0 in-network / Specialist: $0 in-network / Urgently Needed Services: $0 in-network / Mental Health – Group Sessions: $0 in-network / Mental Health – Individual Sessions: $0 in-network / Psychiatric Services – Group Sessions: $0 in-network / Psychiatric Services – Individual Sessions: $0 in-network, for more information see Evidence of Coverage
Inpatient Hospital
$0
Skilled Nursing Facility (SNF)
$0, for more information see Evidence of Coverage.
Emergency Room
$0
Ambulance
$0
Lab Services
$0
Diagnostic Procedures
$0
Imaging
Xray: $0 / CT Scans: $0 / Diagnostic Radiology other than CT Scans: $0/ Diagnostic Radiology Mammogram: $0
Ambulatory Surgery Center (ASC)
$0
Outpatient Mental Health
$0 for Mental Health Group and Individual Sessions, for more information see Evidence of Coverage $0 for Psychiatric Services Group and Individual Sessions, for more information see Evidence of Coverage
Home Health Care
$0
Durable Medical Equipment (DME)
$0
Diabetic Monitoring Supplies
0%
Preventive Benefits
$0 copay for all preventive services covered under Original Medicare at zero cost sharing
Annual Physical
$0
Fitness
Memberships at participating fitness facilities at no added cost to you through our partnership with SilverSneakers. Also access to online wellness related tools, planners, newsletters, and classes.
Dental Coverage
$2,000 maximum benefit for preventive and comprehensive dental services combined – see Evidence of Coverage.
Eyewear Coverage
$200 every year, see the Evidence of Coverage
Hearing Aid Coverage
$1,250 per ear every year, for more information see the Evidence of Coverage
Acupuncture
$0, eighteen visits every year, for more information see Evidence of Coverage.
Meals
$0 copay for 42 meals over 14 days after an inpatient or skilled nursing facility discharge, for more information see Evidence of Coverage
Transportation
Not Covered
Over The Counter (OTC)
$300 every three months
Additional Benefits
Healthy Foods Card: $25 every month / Fall Prevention Devices $150 every year, for more information see Evidence of Coverage
Visitor/Traveler Program
No
Is my dentist in the network?
Prescription Drug Coverage
Annual Prescription Deductible
$0
Initial Coverage Limit – Total amount you and the plan pay on prescription drugs before you enter the coverage gap
$4,430
True Out-of-Pocket Threshold Amount (TrOOP) – Amount you pay before reaching the catastrophic coverage level
$7,050
Preferred Pharmacy – Retail (up to a 30 day supply)
Tier 1 – Preferred Generic Drugs
$0
Tier 2 – Generic Drugs
$0
Tier 3 – Preferred Brand Drugs
$0
Tier 4 – Non-preferred Drugs
$0
Tier 5 – Specialty Drugs
$0
Standard Pharmacy – Retail (up to a 30 day supply)
Tier 1 – Preferred Generic Drugs
$0
Tier 2 – Generic Drugs
$0
Tier 3 – Preferred Brand Drugs
$0
Tier 4 – Non-preferred Drugs
$0
Tier 5 – Specialty Drugs
$0
Mail Order pharmacy – (up to a 100 day supply)
Tier 1 – Preferred Generic Drugs
$0
Tier 2 – Generic Drugs
$0
Tier 3 – Preferred Brand Drugs
$0
Tier 4 – Non-preferred Drugs
$0
Plan Documents
Gives a summary of the plan’s benefits, costs and coverage.
Ofrece un resumen de los beneficios, costos y cobertura del plan.
List of prescription drugs covered by the plan.
Lista de medicamentos recetados cubiertos por el plan.
Work with your doctor to get pre-approval from us before we cover your drug.
You need to try certain drugs first before we cover your drug.
Detailed information on the plan’s benefits, costs and coverage.
Información detallada sobre beneficios, costos y cobertura.
Shows you what your monthly plan premium will be if you get Extra Help from Medicare to pay for your prescription drug costs.
Muestra lo que será su prima mensual del plan si usted obtiene ayuda adicional de Medicare para pagar sus gastos de medicamentos recetados.
We can mail you a kit with most of the items above if you can’t print them. Please allow 7-15 business days for shipping.
Podemos enviarle un kit con la mayoría de los documentos anteriores si no puede imprimirlos. Es posible que lo reciba dentro de los 7 y 15 días.
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Plan: H3312-069-000