Aetna Medicare Eagle Plan (PPO)
H5521 - 350 - 0
(4 / 5)
Aetna Medicare Eagle Plan (PPO) is a Medicare Advantage (Part C) Plan by Aetna Medicare.
This page features plan details for 2024 Aetna Medicare Eagle Plan (PPO) H5521 – 350 – 0 available in Connecticut.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Aetna Medicare Eagle Plan (PPO) is offered in the following locations.
Plan Overview
Aetna Medicare Eagle Plan (PPO) offers the following coverage and cost-sharing.
| Insurer: | Aetna Medicare |
| Health Plan Deductible: | $0.00 |
| MOOP: | $5,900 In and Out-of-network $5,900 In-network |
| Drugs Covered: | No |
Ready to sign up for Aetna Medicare Eagle Plan (PPO) ?
Medicare Part B Give Back Benefit
The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans.
Aetna Medicare Eagle Plan (PPO) qualifies for a monthly Medicare Give Back Benefit of $50.00.
| Premium Reduction: | $50.00 |
Premium Breakdown
Aetna Medicare Eagle Plan (PPO) has a monthly premium of $0.00. This amount includes your Part C premium but does not include your Part B premium.| Part B | Part C | Part B Give Back | Total |
|---|---|---|---|
| $174.70 | $0.00 | $50.00 | $124.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
Aetna Medicare Eagle Plan (PPO) also provides the following benefits.
| $0 |
| In-network | No |
| $5,900 In and Out-of-network $5,900 In-network |
| No |
| In-network | No |
| In-network | $0-295 copay per visit (Authorization is required.) (Referral is not required.) |
| out-of-network | 50% coinsurance per visit (Authorization is required.) (Referral is not required.) |
| In-network Primary | $0 copay (Not applicable.) (Not applicable.) |
| out-of-network Primary | 50% coinsurance per visit (Not applicable.) (Not applicable.) |
| In-network Specialist | $40 copay per visit (Authorization is not required.) (Referral is not required.) |
| out-of-network Specialist | 50% coinsurance per visit (Authorization is not required.) (Referral is not required.) |
| In-network | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network | 0-50% coinsurance (Authorization is not required.) (Referral is not required.) |
| Emergency | $100 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $40 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| In-network Diagnostic tests and procedures | $0-45 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic tests and procedures | 50% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Lab services | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Lab services | 50% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Diagnostic radiology services (e.g., MRI) | $0-115 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic radiology services (e.g., MRI) | 50% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Outpatient x-rays | $0-15 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient x-rays | 50% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Hearing exam | $40 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing exam | 50% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Fitting/evaluation | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Fitting/evaluation | 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Hearing aids | $0-1,700 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing aids | $0-1,700 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Non-routine services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Non-routine services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Diagnostic services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Restorative services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Restorative services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Endodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Endodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Periodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Periodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Extractions | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Extractions | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Prosthodontics, other oral/maxillofacial surgery, other services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Prosthodontics, other oral/maxillofacial surgery, other services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Routine eye exam | 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Other | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Other | 50% coinsurance (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| In-network Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Upgrades | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Upgrades | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Occupational therapy visit | $40 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Occupational therapy visit | 50% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Physical therapy and speech and language therapy visit | $40 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Physical therapy and speech and language therapy visit | 50% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network | $270 copay (Not applicable.) (Not applicable.) |
| out-of-network | $270 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| In-network Foot exams and treatment | $40 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Foot exams and treatment | 50% coinsurance (Authorization is not required.) (Referral is not required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| In-network Durable medical equipment (e.g., wheelchairs, oxygen) | 0-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Durable medical equipment (e.g., wheelchairs, oxygen) | 50% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Prosthetics (e.g., braces, artificial limbs) | 50% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Diabetes supplies | 0-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Diabetes supplies | 0-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| In-network Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Chemotherapy | 50% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Other Part B drugs | 50% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Part B Insulin drugs | $35 copay (Authorization is required.) (Not applicable.) |
| out-of-network Part B Insulin drugs | 50% coinsurance (Authorization is required.) (Not applicable.) |
| In-network | $345 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.) |
| out-of-network | 50% per stay (Authorization is required.) (Referral is not required.) |
| In-network Inpatient hospital – psychiatric | $435 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.) |
| out-of-network Inpatient hospital – psychiatric | 50% per stay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit with a psychiatrist | $40 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit with a psychiatrist | 50% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit with a psychiatrist | $40 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit with a psychiatrist | 50% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit | $40 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit | 50% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit | $40 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit | 50% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network | $0 per day for days 1 through 20 $203 per day for days 21 through 50 $0 per day for days 51 through 100 (Authorization is required.) (Referral is not required.) |
| out-of-network | 50% per stay (Authorization is required.) (Referral is not required.) |
Ready to sign up for Aetna Medicare Eagle Plan (PPO) ?
Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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