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Aetna PPO

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Aetna Medicare Assure Plan (HMO D-SNP) H3312-069

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
Premium
$0.00 monthly
Est. drug cost

Based on 0 drugs

$0 annually
Total est. annual cost
Based on premium and drug costs.
(Effective Jan 2022)
$0 annually
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?
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

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

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

Tier 1 – Preferred Generic Drugs

$0

Tier 2 – Generic Drugs

$0

Tier 3 – Preferred Brand Drugs

$0

Tier 4 – Non-preferred Drugs

$0

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