Aetna Copay For Specialist

Posted : admin On 1/3/2022

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.

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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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2021 Aetna Medicare Medicare Advantage Plan Costs

Plan ID:
Provider:Aetna Medicare
Type: Local HMO
Monthly Premium C+D: $0
Part C Premium: $0
MOOP: $3,600
Part D (Drug) Premium: $0
Part D Supplemental Premium $0
Total Part D Premium: $0
Drug Deductible: $0
Tiers with No Deductible:0
Gap Coverage:Yes
Benchmark:not below the regional benchmark
Type of Medicare Health:Enhanced Alternative
Drug Benefit Type:Enhanced
Similar Plan:H4835-002

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

Additional Benefits


Comprehensive Dental

Diagnostic services$0 copay
Endodontics$0 copay
Extractions$0 copay
Non-routine services$0 copay
Periodontics$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

Doctor Visits

Primary$0 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)
Aetna copay for specialist program

Foot Care (podiatry services)

Foot exams and treatment$25 copay
Routine foot careNot covered

Does aetna require a referral to see a specialist

Ground Ambulance

$280 copay


Fitting/evaluation$0 copay
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

Medical Equipment/Supplies

Diabetes supplies0-20% 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

Chemotherapy20% coinsurance
Other Part B drugs20% 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

Aetna copay for specialist physicians


$3,600 In-network



Optional supplemental benefits

Aetna Medicare Advantage Copays


Outpatient Hospital Coverage

$0-185 copay per visit

Preventive Care

$0 copay

Preventive Dental

Cleaning$0 copay
Dental x-ray(s)$0 copay
Fluoride treatment$0 copay
Oral exam$0 copay

Rehabilitation Services

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


Not covered

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
Other$0 copay
Routine eye exam$0 copay
Upgrades$0 copay

Wellness Programs (e.g. fitness nursing hotline)


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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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Source: CMS.
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.

Table of rates.
Open Access® HMO - BasicCodeNon-PostalPostal 1Postal 2
Click to learn more about non-postal, postal 1 and postal 2 rates

2021 benefits

(for a 30-day supply at a retail pharmacy)
Table of rates.
Plan DetailsBasic Option
Preventive care copay$0
Primary care visit copay$15
Specialist visit copay$35
Prenatal Care$0
Hospital CareWe pay 80% / You pay 20%
Inpatient hospital chargesWe pay 80% / You pay 20%
Surgery and AnesthesiaWe pay 100% / You pay nothing
Facility ChargesWe 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
Generic formulary*$5
Brand-name formulary*$35

For specialty drug information, see the federal plan brochure.
Your plan requires the use of generic medication when a generic equivalent exists. ***
Or get a 90-day supply for only 2 copays, not 3, through mail-order service or available at CVS Retail.

Built-in Vision
Routine eye exam copay$35
Money toward prescription eyewearYou get $200 every 24 months
Discounts on eyeglasses, contacts, eye exams and moreIncluded

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.