Aetna Er Copay

Posted : admin On 1/3/2022
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View the 2021 Standard Option plan

Prescription drug copays for Tier 3 medications on the Aetna ACO plans in Texas, Arizona and Colorado will change from 50% coinsurance to a $75 copay. The in-network family deductible and maximum out-of-pocket expenses for some Aetna medical plans will be changing. Please see the table below. You pay a copay when you receive care from network providers – NO REFERRALS NEEDED You pay the entire cost if you receive care from a non-network provider, except in a health emergency Preventive Care covered 100% Aetna Health Connections, Disease Management, Informed Health Line, and Beginning Right Maternity programs included at no extra cost.

Traditional coverage. Affordable premiums.

With comprehensive care, this medical plan is the one you know and trust, with familiar benefits and coverage

When you enroll in GEHA’s Standard Option, you:

  • Pay nothing for online doctor visits with access to certified doctors, including dermatologists, and licensed therapists through MDLIVE.
  • Pay nothing for routine, in-network maternity care.
  • Get a complete range of prescription services.

More Standard Option highlights:

  • A 30-day supply of generic medication costs just $10.
  • You can visit your primary care doctor for only a $15 copay each visit.
  • This plan covers 100% of preventive care costs when you see an in-network provider.

2020 Rates

Cost

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 that maintains your health benefits enrollment.

Self OnlySelf Plus OneSelf and Family
Non-Postal biweekly$60.54$130.18$155.52
Postal biweekly – Category 1 $58.12$124.97$149.30
Postal biweekly – Category 2 $50.25$108.05$129.08
Monthly (retirees)$131.18$282.05$336.96

Pay nothing for online doctor visits with access to certified doctors, including dermatologists, and licensed therapists through MDLIVE.

A 30-day supply of generic medication costs just $10.

You can visit your primary care doctor for only a $15 copay each visit.

Covered benefits for routine in-network maternity care and hospital stays.

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Costs for services in 2020

The table below summarizes your in-network cost for medical benefits with GEHA Standard Option. For complete information, refer to the GEHA Plan Brochure.

Copays

CopayWhat you pay in-network
Primary physician office visit$15
Specialist$30
MinuteClinic (where available)$10
Urgent care$35
Annual eye exam$5 through EyeMed

Other services

ServiceWhat you pay in-network
Preventive lab servicesNothing with Lab Card
Well-child visit; up to age 22Nothing
Adult routine screeningNothing
Preventive dental care50% of allowance, twice yearly

Maternity care

ServiceWhat you pay in-network
Routine provider careNothing
Inpatient careNothing
Self OnlySelf Plus OneSelf and Family
Calendar-year deductible (in-network)$350$700$700
Out-of-pocket-maximum (in-network)$6,500$13,000$13,000

Prescriptions

The table below summarizes your cost for prescription drugs with GEHA’s Standard Option. For complete benefit information, including details on specialty drugs that are injected or infused, refer to the GEHA Plan Brochure.

To find a drug cost based on your benefit plan and prescription dosage, check your drug costs.

Retail pharmacy – 30-day supply

In-NetworkOut of Network
Generic$10$10, plus difference between plan allowance and cost of drug
Preferred brand-name50%, up to $200 max¤50%, up to $200 max, plus difference between plan allowance and cost of drug**¤
Non-preferred brand-name50%, up to $300 max¤50%, up to $300 max, plus difference between plan allowance and cost of drug**¤

Mail service pharmacy – 90-day supply

In-NetworkOut of Network
Generic$20n/a
Preferred brand-name50%, up to $500 max¤n/a
Non-preferred brand-name50%, up to $600 max¤n/a

¤If you choose a brand-name medication when a generic is available, you will be charged the generic copay plus the difference in cost between the brand-name and the generic.

**Retail fills eligible for a greater than a 30-day supply will be subject to the 50% coinsurance up to the maximum of $500 for preferred or $600 for non-preferred.

HEALTH REWARDS
Up to $250 in incentives for Standard Option members who complete simple and convenient health screenings.
VISION COVERAGE
Get in-network routine eye exams for $5 and discounts on eyewear.
GYM DISCOUNTS
Access over 10,000 fitness centers nationwide for $25 a month (plus a $25 enrollment fee and taxes).

^GEHA supplemental benefits are neither offered nor guaranteed under contract with the FEHB, but are made available to all enrollees and family members who become members of a GEHA medical plan. For information on year-round savings for GEHAdental members, visit Savings for GEHA dental members.

This is a brief description of the features of the GEHA Standard Option medical plan. Before making a final decision, please read the Plan’s Federal brochure RI 71-006. All benefits are subject to the definitions, limitations and exclusions set forth in the Federal brochure.
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Aetna Medicare Premier Plus (PPO) H1608-016 is a 2020 Medicare Advantage Plan or Medicare Part-C plan by Aetna Medicare available to residents in Kansas Missouri. This plan includes additional Medicare prescription drug (Part-D) coverage. The Aetna Medicare Premier Plus (PPO) has a monthly premium of $- and has an in-network Maximum Out-of-Pocket limit of $6,200 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $6,200 out of pocket. This can be a extremely nice safety net.

Aetna Medicare Premier Plus (PPO) is a Local PPO. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of 'preferred' providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.

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 Premier Plus (PPO) 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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Sun 9am-6pm EST



2020 Aetna Medicare Medicare Advantage Plan Details

Name:
ID:
H1608-016
Provider:Aetna Medicare
Year:2020
Type: Local PPO
Monthly Premium C+D: $-
Part C Premium:$0.00
MOOP: $6,200
Part D (Drug) Premium:$0.00
Part D Supplemental Premium$0.00
Total Part D Premium:$0.00
Drug Deductible:$0.00
Tiers with No Deductible:0
Gap Coverage:Yes
Benchmark:not below the regional benchmark
Type of Medicare Health:Enhanced Alternative
Drug Benefit Type:Enhanced

Part-C Premium

Aetna Medicare plan charges a $0.00 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.


Part-D Deductible and Premium

Aetna Medicare Premier Plus (PPO) has a monthly drug premium of $0.00 and a $0.00 drug deductible. This Aetna Medicare plan offers a $0.00 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 $0.00 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 $0.00. 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.


Premium Assistance

Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The Aetna Medicare Premier Plus (PPO) medicare insurance offers a $0.00 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $0.00 for 75% low income subsidy $0.00 for 50% and $0.00 for 25%.


Full LIS Premium:$0.00
75% LIS Premium:$0.00
50% LIS Premium:$0.00
25% LIS Premium:$0.00

Gap Coverage

In 2020 once you and your plan provider have spent $4020 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.


Aetna Medicare Drug Coverage and Formulary

A formulary is divided into tiers or levels of coverage based on the type or usage of your medication or benefit categories, according to drug costs. Each tier will have a defined out-of-pocket cost that you must pay before receiving the drug. You can see complete 2020 Aetna Medicare Premier Plus (PPO) H1608-016 Formulary here.


See the 2020 Aetna Medicare Formulary


2019 Plan Services

(*2020 Plan services will be added when available)



Health plan deductible


$0


Emergency care/Urgent care


Emergency$90 per visit (always covered)
Urgent care$50 per visit (always covered)


Diagnostic procedures/lab services/imaging


Diagnostic tests and proceduresOut-of-Network45%
Diagnostic tests and proceduresIn-Network$0 copay
Lab servicesOut-of-Network45%
Lab servicesIn-Network$0 copay
Diagnostic radiology services (e.g., MRI)Out-of-Network45%
Diagnostic radiology services (e.g., MRI)In-Network$50-190
Outpatient x-raysOut-of-Network45%
Outpatient x-raysIn-Network$0


Hearing


Hearing examOut-of-Network45%
Hearing examIn-Network$50
Fitting/evaluationNot covered
Hearing aids - inner earNot covered
Hearing aids - outer earNot covered
Hearing aids - over the earNot covered


Preventive dental


Oral examOut-of-Network$0 copay
Oral examIn-Network$0 copay
CleaningOut-of-Network$0 copay
CleaningIn-Network$0 copay
Fluoride treatmentNot covered
Dental x-ray(s)Out-of-Network$0 copay
Dental x-ray(s)In-Network$0 copay


Comprehensive dental


Non-routine servicesNot covered
Diagnostic servicesNot covered
Restorative servicesNot covered
EndodonticsNot covered
PeriodonticsNot covered
ExtractionsNot covered
Prosthodontics, other oral/maxillofacial surgery, other servicesNot covered


Vision


Routine eye examOut-of-Network45%
Routine eye examIn-Network$0 copay
OtherNot covered
Contact lensesOut-of-Network45%
Contact lensesIn-Network$0 copay
Eyeglasses (frames and lenses)Out-of-Network45%
Eyeglasses (frames and lenses)In-Network$0 copay
Eyeglass framesOut-of-Network45%
Eyeglass framesIn-Network$0 copay
Eyeglass lensesOut-of-Network45%
Eyeglass lensesIn-Network$0 copay
UpgradesOut-of-Network45%
UpgradesIn-Network$0 copay


Mental health services


Inpatient hospital - psychiatricOut-of-Network45% per stay
Inpatient hospital - psychiatricIn-Network$290 per day for days 1 through 5
$0 per day for days 6 through 90
Outpatient group therapy visit with a psychiatristOut-of-Network45%
Outpatient group therapy visit with a psychiatristIn-Network$40
Outpatient individual therapy visit with a psychiatristOut-of-Network45%
Outpatient individual therapy visit with a psychiatristIn-Network$40
Outpatient group therapy visitOut-of-Network45%
Outpatient group therapy visitIn-Network$40
Outpatient individual therapy visitOut-of-Network45%
Outpatient individual therapy visitIn-Network$40


Skilled Nursing Facility


Out-of-Network45% per stay
In-Network$0 per day for days 1 through 20
$167.50 per day for days 21 through 100


Rehabilitation services


Occupational therapy visitOut-of-Network45%
Occupational therapy visitIn-Network$40
Physical therapy and speech and language therapy visitOut-of-Network45%
Physical therapy and speech and language therapy visitIn-Network$40

Aetna Select Open Access Providers


Ground ambulance


Out-of-Network$310
In-Network$310


Other health plan deductibles?


In-NetworkNo


Transportation


Out-of-Network$0 copay
In-Network$0 copay


Foot care (podiatry services)


Foot exams and treatmentOut-of-Network45%
Foot exams and treatmentIn-Network$50
Routine foot careNot covered


Medical equipment/supplies


Durable medical equipment (e.g., wheelchairs, oxygen)Out-of-Network20% per item
Durable medical equipment (e.g., wheelchairs, oxygen)In-Network20% per item
Prosthetics (e.g., braces, artificial limbs)Out-of-Network20% per item
Prosthetics (e.g., braces, artificial limbs)In-Network20% per item
Diabetes suppliesOut-of-Network0-20% per item
Diabetes suppliesIn-Network0-20% per item


Wellness programs (e.g., fitness, nursing hotline)


Covered


Medicare Part B drugs


ChemotherapyOut-of-Network45%
ChemotherapyIn-Network20%
Other Part B drugsOut-of-Network45%
Other Part B drugsIn-Network20%


Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)


$10,000 In and Out-of-network
$6,200 In-network


Optional supplemental benefits


Yes


Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?


In-NetworkNo


Inpatient hospital coverage


Out-of-Network45% per stay
In-Network$290 per day for days 1 through 5
$0 per day for days 6 through 90


Outpatient hospital coverage


Out-of-Network45% per visit
In-Network$250 per visit

Does Aetna Cover Er Visits



Doctor visits


PrimaryOut-of-Network45% per visit
PrimaryIn-Network$5 per visit
SpecialistOut-of-Network45% per visit
SpecialistIn-Network$50 per visit


Preventive care


Out-of-Network0-45%
In-Network$0 copay

Ratings for Aetna Medicare Premier Plus (PPO) H1608

2019 Overall Rating
Part C Summary Rating
Part D Summary Rating
Staying Healthy: Screenings, Tests, Vaccines
Managing Chronic (Long Term) Conditions
Member Experience with Health Plan
Complaints and Changes in Plans Performance
Health Plan Customer Service
Drug Plan Customer Service
Complaints and Changes in the Drug Plan
Member Experience with the Drug Plan
Drug Safety and Accuracy of Drug Pricing

Staying Healthy, Screening, Testing, & Vaccines

Aetna Ppo Er Copay

Total Preventative Rating
Breast Cancer Screening
Colorectal Cancer Screening
Annual Flu Vaccine
Improving Physical
Improving Mental Health
Monitoring Physical Activity
Adult BMI Assessment

Managing Chronic And Long Term Care for Older Adults

Total Rating
SNP Care Management
Medication Review
Functional Status Assessment
Pain Screening
Osteoporosis Management
Diabetes Care - Eye Exam
Diabetes Care - Kidney Disease
Diabetes Care - Blood Sugar
Rheumatoid Arthritis
Reducing Risk of Falling
Improving Bladder Control
Medication Reconciliation
Plan All-Cause Readmissions
Statin Therapy

Member Experience with Health Plan

Total Experience Rating
Getting Needed Care
Timely Care and Appointments
Customer Service
Health Care Quality
Rating of Health Plan
Care Coordination

Member Complaints and Changes in Aetna Medicare Premier Plus (PPO) Plans Performance

Total Rating
Complaints about Health Plan
Members Leaving the Plan
Health Plan Quality Improvement

Health Plan Customer Service Rating for Aetna Medicare Premier Plus (PPO)

Total Customer Service Rating
Timely Decisions About Appeals
Reviewing Appeals Decisions
Call Center, TTY, Foreign Language

Aetna Medicare Premier Plus (PPO) Drug Plan Customer Service ratings

Total Rating
Call Center, TTY, Foreign Language
Appeals Auto
Appeals Upheld

Aetna Er Copay

Ratings For Member Complaints and Changes in the Drug Plans Performance

Total Rating
Complaints about the Drug Plan
Members Choosing to Leave the Plan
Drug Plan Quality Improvement

Member Experience with the Drug Plan

Total Rating
Rating of Drug Plan
Getting Needed Prescription Drugs

Does Aetna Cover Emergency Room


Drug Safety and Accuracy of Drug Pricing

Total Rating
MPF Price Accuracy
Drug Adherence for Diabetes Medications
Drug Adherence for Hypertension (RAS antagonists)
Drug Adherence for Cholesterol (Statins)
MTM Program Completion Rate for CMR
Statin with Diabetes


Ready to Enroll?


Or Call
1-855-778-4180
Mon-Sat 8am-11pm EST
Sun 9am-6pm EST



Coverage Area for Aetna Medicare Premier Plus (PPO)

(Click county to compare all available Advantage plans)

State:Kansas
Missouri
County:Allen, Anderson, Atchison, Bates, Benton,
Bourbon, Caldwell, Carroll, Cass,
Clay, Clinton, Douglas, Franklin,
Henry, Jackson, Jefferson, Johnson,
Johnson, Lafayette, Leavenworth, Linn,
Livingston, Miami, Pettis, Platte,
Ray, Saline, Shawnee, Vernon,

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Aetna Copay Amounts

Source: CMS.
Data as of September 4, 2019.
Star Rating as of October 10, 2019.
Plan Services are 2019 information as reference. 2020 information will be added when released.
Notes: Data are subject to change as contracts are finalized. For 2020, 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 2020 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.