Mar 22, 2021 Medicare provides you with coverage for health-related expenses, but it doesn’t cover everything. There are a number of gaps in Medicare coverage. Learn how a Medicare Supplement Insurance plan can help you fill them. You pay $0 copay, for cleanings and X-Rays, when you use our dental preferred provider organization (PPO) network.A formulary is a list of generic and brand-name drugs your health plan prefers. If you choose the brand name drug over the generic equivalent, you will owe the corresponding copay plus the difference between the generic. This Aetna Medicare plan does offer additional coverage through the gap. H4835-001 Formulary or Drug Coverage. Aetna Medicare Prime Plus Plan (HMO) formulary is divided into tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug.
- Aetna Medicare Advantage Copays
- Aetna Copay For Specialist Dental
- Aetna Copay For Specialist Physicians
- Does Aetna Cover Doctor Visits
- Aetna Copay For Specialist Group
- Aetna Copay Information
Aetna Medicare Prime Plus Plan (HMO) H4835-001 is a 2021 Medicare Advantage Plan or Medicare Part-C plan by Aetna Medicare available to residents in Arizona. This plan includes additional Medicare prescription drug (Part-D) coverage. The Aetna Medicare Prime Plus Plan (HMO) has a monthly premium of $0 and has an in-network Maximum Out-of-Pocket limit of $3,600 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $3,600 out of pocket. This can be a extremely nice safety net.
Aetna Medicare Prime Plus Plan (HMO) is a Local HMO. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your PCP will serve as your personal doctor to provide all of your basic healthcare services. If you require specialized care or a physician specialist, your primary care physician will make the arrangements and inform you where you can go in the network. You will need your PCPs okay, called a referral. Services received from an out-of-network provider are not typically covered by the plan.
Aetna Medicare works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Aetna Medicare Prime Plus Plan (HMO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Aetna Medicare and not Original Medicare. With Medicare Advantage Plans you are always covered for urgently needed and emergency care. Plus you receive all of the benefits of Original Medicare from Aetna Medicare except hospice care. Original Medicare still provides you with hospice care even if you sign up for a Medicare Advantage Plan.
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Mon-Fri 8am-9pm EST
Sat 9am-9pm EST
2021 Aetna Medicare Medicare Advantage Plan Costs
|Monthly Premium C+D:||$0|
|Part C Premium:||$0|
|Part D (Drug) Premium:||$0|
|Part D Supplemental Premium||$0|
|Total Part D Premium:||$0|
|Tiers with No Deductible:||0|
|Benchmark:||not below the regional benchmark|
|Type of Medicare Health:||Enhanced Alternative|
|Drug Benefit Type:||Enhanced|
Aetna Medicare Prime Plus Plan (HMO) Part-C Premium
Aetna Medicare plan charges a $0 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.
H4835-001 Part-D Deductible and Premium
Aetna Medicare Prime Plus Plan (HMO) has a monthly drug premium of $0 and a $0 drug deductible. This Aetna Medicare plan offers a $0 Part D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0 this Premium covers any enhanced plan benefits offered by Aetna Medicare above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $0 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lower due to negative basic or supplemental premiums.
Aetna Medicare Gap Coverage
In 2021 once you and your plan provider have spent $4130 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA 'donut hole') You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This Aetna Medicare plan does offer additional coverage through the gap.
H4835-001 Formulary or Drug Coverage
Aetna Medicare Prime Plus Plan (HMO) formulary is divided into tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers.By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price.
2021 Aetna Medicare Prime Plus Plan (HMO) Summary of Benefits
|Diagnostic services||$0 copay|
|Non-routine services||$0 copay|
|Prosthodontics, other oral/maxillofacial surgery, other services||$0 copay|
|Restorative services||$0 copay|
Diagnostic Tests and Procedures
|Diagnostic radiology services (e.g., MRI)||$0-150 copay|
|Diagnostic tests and procedures||$0-10 copay|
|Lab services||$0 copay|
|Outpatient x-rays||$10 copay|
|Specialist||$25 copay per visit|
Emergency care/Urgent Care
|Emergency||$90 copay per visit (always covered)|
|Urgent care||$50 copay per visit (always covered)|
Foot Care (podiatry services)
|Foot exams and treatment||$25 copay|
|Routine foot care||Not covered|
|Hearing aids||$0 copay|
|Hearing exam||$0 copay|
Inpatient Hospital Coverage
|$195 per day for days 1 through 7|
$0 per day for days 8 through 90
|Diabetes supplies||0-20% coinsurance per item|
|Durable medical equipment (e.g., wheelchairs, oxygen)||20% coinsurance per item|
|Prosthetics (e.g., braces, artificial limbs)||20% coinsurance per item|
Medicare Part B Drugs
|Other Part B drugs||20% coinsurance|
Mental Health Services
|Inpatient hospital - psychiatric||$370 per day for days 1 through 5|
$0 per day for days 6 through 90
|Outpatient group therapy visit||$40 copay|
|Outpatient group therapy visit with a psychiatrist||$40 copay|
|Outpatient individual therapy visit||$40 copay|
|Outpatient individual therapy visit with a psychiatrist||$40 copay|
Optional supplemental benefits
Aetna Medicare Advantage Copays
Outpatient Hospital Coverage
|$0-185 copay per visit|
|Dental x-ray(s)||$0 copay|
|Fluoride treatment||$0 copay|
|Oral exam||$0 copay|
|Occupational therapy visit||$25 copay|
|Physical therapy and speech and language therapy visit||$25 copay|
Skilled Nursing Facility
|$0 per day for days 1 through 20|
$184 per day for days 21 through 100
Aetna Copay For Specialist Dental
Aetna Copay For Specialist Physicians
|Contact lenses||$0 copay|
|Eyeglass frames||$0 copay|
|Eyeglass lenses||$0 copay|
|Eyeglasses (frames and lenses)||$0 copay|
|Routine eye exam||$0 copay|
Wellness Programs (e.g. fitness nursing hotline)
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Mon-Sat 8am-11pm EST
Sun 9am-6pm EST
Coverage Area for Aetna Medicare Prime Plus Plan (HMO)
(Click county to compare all available Advantage plans)
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Data as of September 9, 2020.
Notes: Data are subject to change as contracts are finalized. For 2021, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part D benefit.Includes 2021 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.
2021 Biweekly rates for zip code
These rates do not apply to all Enrollees. If you are in a special enrollment category, please refer to the FEHB Program website or contact the agency or Tribal Employer which maintains your health benefits enrollment.
|Open Access® HMO - Basic||Code||Non-Postal||Postal 1||Postal 2|
(for a 30-day supply at a retail pharmacy)
|Plan Details||Basic Option|
|Preventive care copay||$0|
|Primary care visit copay||$15|
|Specialist visit copay||$35|
|Hospital Care||We pay 80% / You pay 20%|
|Inpatient hospital charges||We pay 80% / You pay 20%|
|Surgery and Anesthesia||We pay 100% / You pay nothing|
|Facility Charges||We pay 80% / You pay 20%|
|Outpatient surgery copay||$750|
|Emergency room copay||$250|
|Urgent care center copay||$100|
|Lab/X-ray/diagnostic services||$15 PCP / $35 specialist ($75 for certain tests)|
|Prescription drug copays|
For specialty drug information, see the federal plan brochure.
|Routine eye exam copay||$35|
|Money toward prescription eyewear||You get $200 every 24 months|
|Discounts on eyeglasses, contacts, eye exams and more||Included|
Built-in dental, too
Use our Basic Dental Network. Call 1-800-537-9384 to select a dentist OR to switch to our larger PPO network at no additional cost. It's your choice!
Basic - Pay a $5 copay for cleanings, fillings and X-rays when you visit your primary care dentist (PCD).
PPO - After a $20 deductible per member, cleanings, fillings, and X-rays are covered at 100% with network dentists.**
- Large nationwide Aetna HMO Network
- 24/7 access to doctors via phone or video with Teladoc®†
- Built-in dental and vision coverage
- Predictable costs
- No referrals to network specialists*
- Discounts on eyewear, LASIK surgery, gym memberships, massage, acupuncture, weight-loss programs and more
*A formulary is a list of generic and brand-name drugs your health plan prefers.
** Out of Network for cleanings, composite fillings and X-rays – you pay 50% of negotiated rate plus any difference between our allowance and the billed amount.
*** If you choose the brand name drug over the generic equivalent, you will owe the corresponding copay plus the difference between the generic and brand name costs. Please see the plan brochure for details.
†Teladoc® is covered at the member cost share.
] Teladoc and Teladoc physicians are independent contractors and are neither agents nor employees of Aetna. Teladoc does not replace the primary care physician. Teladoc does not guarantee that a prescription will be written. Teladoc operates subject to state regulation and may not be available in certain states. Teladoc does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. Teladoc physicians reserve the right to deny care for potential misuse of services.
Does Aetna Cover Doctor Visits
Health insurance plans are offered, underwritten and/or administered by Aetna Life Insurance Company (Aetna).
This is a brief description of the features of this Aetna health benefits plan. Before making a decision, please read the Plan's applicable Federal brochure(s). All benefits are subject to the definitions, limitations, and exclusions set forth in the Federal brochure. Plan features and availability may vary by location and are subject to change. Pharmacy clinical programs such as precertification, step therapy, and quantity limits may apply to your prescription drug coverage. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Discount programs are neither offered nor guaranteed under our contract with the FEHB Program, but are made available to all enrollees and their families who become members under an Aetna Health Insurance Plan. Discount programs provide access to discounted prices and are NOT insured benefits. The member is responsible for the full cost of the discounted services. Incentive-based activity awards will only be given for completing select wellness programs as determined by the plan sponsor. Information is believed to be accurate as of the production date; however, it is subject to change.
Postal and Non-Postal rates
Aetna Copay For Specialist Group
Aetna Copay Information
- Non-Postal rates apply to most non-Postal employees.
- Postal rates apply to United States Postal Service employees.
- Postal Category 1 rates apply to career bargaining unit employees represented by the APWU, IT/AS, NALC and NPMHU.
- Postal Category 2 rates apply to career bargaining unit employees represented by the PPOA.
- Non-Postal rates apply to all career non-bargaining unit Postal Service employees and career employees represented by the NRLCA agreement.