Aetna Medicare Essential Plan (PPO)
H5521 - 354 - 0
(3.5 / 5)
Aetna Medicare Essential Plan (PPO) is a Medicare Advantage Plan by Aetna Medicare.
This page features plan details for 2023 Aetna Medicare Essential Plan (PPO) H5521 – 354 – 0.
IMPORTANT: This page features the 2023 version of this plan. See the 2025 version using the link below:
No 2025 version found. You can use the location links below to find 2025 plans in your area.
Locations
Aetna Medicare Essential Plan (PPO) is offered in the following locations.
Plan Overview
Aetna Medicare Essential Plan (PPO) offers the following coverage and cost-sharing.
| Insurer: | Aetna Medicare |
| Health Plan Deductible: | $0.00 |
| MOOP: | $11,300 In and Out-of-network $7,500 In-network |
| Drugs Covered: | Yes |
Please Note:
- This plan does not charge an annual deductible for all drugs. The $200.00 annual deductible only applies to drugs on certain tiers.
Ready to sign up for Aetna Medicare Essential Plan (PPO) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST
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 Essential Plan (PPO) qualifies for a monthly Medicare Give Back Benefit of $35.00.
| Premium Reduction: | $35.00 |
Premium Breakdown
Aetna Medicare Essential Plan (PPO) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $164.90 | $0.00 | $0.00 | $35.00 | $ |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
- You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.
Drug Info
Aetna Medicare Essential Plan (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $200.00 |
| Initial Coverage Limit: | $4,660.00 |
| Catastrophic Coverage Limit: | $7,400.00 |
| Drug Benefit Type: | Enhanced |
| Gap Coverage: | Yes |
| Formulary Link: | Formulary Link |
Part D Premium Reduction
The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs. The table below shows how the LIS impacts the Part D premium of this plan.| Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
|---|---|---|---|---|
| $0.00 | $43.40 | $34.80 | $26.30 | $17.70 |
Initial Coverage Phase
After you pay your $200.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $15.00 copay | $0.00 copay | $15.00 copay |
| 2 (Generic) | $10.00 copay | $20.00 copay | $10.00 copay | $20.00 copay |
| 3 (Preferred Brand) | $47.00 copay | $47.00 copay | $47.00 copay | $47.00 copay |
| 4 (Non-Preferred Drug) | $100.00 copay | $100.00 copay | $100.00 copay | $100.00 copay |
| 5 (Specialty Tier) | 29% | 29% | 29% | 29% |
60 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | ||||
| 2 (Generic) | ||||
| 3 (Preferred Brand) | ||||
| 4 (Non-Preferred Drug) | ||||
| 5 (Specialty Tier) |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $45.00 copay | $0.00 copay | $45.00 copay |
| 2 (Generic) | $25.00 copay | $60.00 copay | $25.00 copay | $60.00 copay |
| 3 (Preferred Brand) | $141.00 copay | $141.00 copay | $141.00 copay | $141.00 copay |
| 4 (Non-Preferred Drug) | $300.00 copay | $300.00 copay | $300.00 copay | $300.00 copay |
| 5 (Specialty Tier) |
Gap Coverage Phase
30 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $15.00 copay | $0.00 copay | $15.00 copay |
| 2 (Generic) | $10.00 copay | $20.00 copay | $10.00 copay | $20.00 copay |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $45.00 copay | $0.00 copay | $45.00 copay |
| 2 (Generic) | $25.00 copay | $60.00 copay | $25.00 copay | $60.00 copay |
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,400.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
| Drug Type | Cost Share |
|---|---|
| Generic drugs | $4.15 copay or 5% (whichever costs more) |
| Brand-name drugs | $10.35 copay or 5% (whichever costs more) |
Additional Benefits
Aetna Medicare Essential Plan (PPO) also provides the following benefits.
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
| In-Network: No |
Dental (comprehensive)
| Diagnostic services: | In-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
| Diagnostic services: | Out-of-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
| Endodontics: | In-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
| Endodontics: | Out-of-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
| Extractions: | In-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
| Extractions: | Out-of-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
| Non-routine services: | In-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
| Non-routine services: | Out-of-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
| Periodontics: | In-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
| Periodontics: | Out-of-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | In-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | Out-of-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
| Restorative services: | In-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
| Restorative services: | Out-of-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
Dental (preventive)
| Cleaning: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Cleaning: | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Dental x-ray(s): | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Dental x-ray(s): | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Fluoride treatment: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Fluoride treatment: | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Oral exam: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Oral exam: | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
Diagnostic procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | In-Network: $0-120 copay (authorization required) (referral not required) |
| Diagnostic radiology services (e.g., MRI): | Out-of-Network: 50% coinsurance (authorization required) (referral not required) |
| Diagnostic tests and procedures: | In-Network: $0-75 copay (authorization required) (referral not required) |
| Diagnostic tests and procedures: | Out-of-Network: 50% coinsurance (authorization required) (referral not required) |
| Lab services: | In-Network: $0 copay (authorization required) (referral not required) |
| Lab services: | Out-of-Network: 50% coinsurance (authorization required) (referral not required) |
| Outpatient x-rays: | In-Network: $14 copay (authorization required) (referral not required) |
| Outpatient x-rays: | Out-of-Network: 50% coinsurance (authorization required) (referral not required) |
Doctor visits
| Primary: | In-Network: $0 copay |
| Primary: | Out-of-Network: $55 copay per visit |
| Specialist: | In-Network: $50 copay per visit (authorization not required) (referral not required) |
| Specialist: | Out-of-Network: $60 copay per visit (authorization not required) (referral not required) |
Emergency care/Urgent care
| Emergency: | $90 copay per visit (always covered) |
| Urgent care: | $0-50 copay per visit (always covered) |
Foot care (podiatry services)
| Foot exams and treatment: | In-Network: $50 copay (authorization not required) (referral not required) |
| Foot exams and treatment: | Out-of-Network: $60 copay (authorization not required) (referral not required) |
| Routine foot care: | Not covered |
Ground ambulance
| In-Network: $260 copay | |
| Out-of-Network: $260 copay |
Health plan deductible
| $0.00 |
Health plan deductibles (other)
| In-Network: No |
Hearing
| Fitting/evaluation: | In-Network: $50 copay (limits may apply) (authorization not required) (referral not required) |
| Fitting/evaluation: | Out-of-Network: $60 copay (limits may apply) (authorization not required) (referral not required) |
| Hearing aids – inner ear: | Not covered (no limits) |
| Hearing aids – outer ear: | Not covered (no limits) |
| Hearing aids – over the ear: | Not covered (no limits) |
| Hearing exam: | In-Network: $50 copay (authorization not required) (referral not required) |
| Hearing exam: | Out-of-Network: $60 copay (authorization not required) (referral not required) |
Hospital coverage (inpatient)
| In-Network: $400 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) (referral not required) | |
| Out-of-Network: 50% per stay (authorization required) (referral not required) |
Hospital coverage (outpatient)
| In-Network: $0-350 copay per visit (authorization required) (referral not required) | |
| Out-of-Network: 50% coinsurance per visit (authorization required) (referral not required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $11,300 In and Out-of-network $7,500 In-network |
Medical equipment/supplies
| Diabetes supplies: | In-Network: 0-20% coinsurance per item (authorization required) |
| Diabetes supplies: | Out-of-Network: 0-20% coinsurance per item (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | In-Network: 20% coinsurance per item (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | Out-of-Network: 45% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | In-Network: 20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | Out-of-Network: 45% coinsurance per item (authorization required) |
Medicare Part B drugs
| Chemotherapy: | In-Network: 20% coinsurance (authorization required) |
| Chemotherapy: | Out-of-Network: 50% coinsurance (authorization required) |
| Other Part B drugs: | In-Network: 20% coinsurance (authorization required) |
| Other Part B drugs: | Out-of-Network: 50% coinsurance (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | In-Network: $400 per day for days 1 through 4 $0 per day for days 5 through 90 (authorization required) (referral not required) |
| Inpatient hospital – psychiatric: | Out-of-Network: 50% per stay (authorization required) (referral not required) |
| Outpatient group therapy visit: | In-Network: $40 copay (authorization required) (referral not required) |
| Outpatient group therapy visit: | Out-of-Network: 50% coinsurance (authorization required) (referral not required) |
| Outpatient group therapy visit with a psychiatrist: | In-Network: $40 copay (authorization required) (referral not required) |
| Outpatient group therapy visit with a psychiatrist: | Out-of-Network: 50% coinsurance (authorization required) (referral not required) |
| Outpatient individual therapy visit: | In-Network: $40 copay (authorization required) (referral not required) |
| Outpatient individual therapy visit: | Out-of-Network: 50% coinsurance (authorization required) (referral not required) |
| Outpatient individual therapy visit with a psychiatrist: | In-Network: $40 copay (authorization required) (referral not required) |
| Outpatient individual therapy visit with a psychiatrist: | Out-of-Network: 50% coinsurance (authorization required) (referral not required) |
Optional supplemental benefits
| No |
Preventive care
| In-Network: $0 copay (authorization not required) (referral not required) | |
| Out-of-Network: $0 copay (authorization not required) (referral not required) |
Rehabilitation services
| Occupational therapy visit: | In-Network: $35 copay (authorization required) (referral not required) |
| Occupational therapy visit: | Out-of-Network: 50% coinsurance (authorization required) (referral not required) |
| Physical therapy and speech and language therapy visit: | In-Network: $35 copay (authorization required) (referral not required) |
| Physical therapy and speech and language therapy visit: | Out-of-Network: 50% coinsurance (authorization required) (referral not required) |
Skilled Nursing Facility
| In-Network: $0 per day for days 1 through 20 $196 per day for days 21 through 100 (authorization required) (referral not required) | |
| Out-of-Network: 50% per stay (authorization required) (referral not required) |
Transportation
| Not covered |
Vision
| Contact lenses: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Contact lenses: | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglass frames: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglass frames: | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglass lenses: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglass lenses: | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglasses (frames and lenses): | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglasses (frames and lenses): | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Other: | In-Network: $0 copay (no limits) (authorization not required) (referral not required) |
| Other: | Out-of-Network: $60 copay (no limits) (authorization not required) (referral not required) |
| Routine eye exam: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Routine eye exam: | Out-of-Network: $60 copay (limits may apply) (authorization not required) (referral not required) |
| Upgrades: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Upgrades: | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
Wellness programs (e.g., fitness, nursing hotline)
| Covered (authorization not required) (referral not required) |
Ready to sign up for Aetna Medicare Essential Plan (PPO) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST