2022 Aetna Medicare Prime (PPO)

Aetna Medicare Prime (PPO) H1608-004 is a 2022 Medicare Advantage Plan or Part-C by Aetna Medicare available to residents in South Dakota. This plan includes additional prescription drug (Part-D) coverage. The Aetna Medicare Prime (PPO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $5,400 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $5,400 out-of-pocket. This can be a extremely nice safety net.

Aetna Medicare Prime (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 Prime (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 you are always covered for urgently needed and emergency care. Plus you receive all 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 Medicare Advantage.

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2022 Aetna Medicare Medicare Advantage Plan Costs

Aetna Medicare Prime (PPO) Part-C Premium

Aetna Medicare 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.

H1608-004 Part-D Deductible and Premium

Aetna Medicare Prime (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 lowered due to negative basic or supplemental premiums.

Aetna Medicare Gap Coverage

In 2022 once you and your plan provider have spent $4430 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.

H1608-004 Formulary or Drug Coverage

Aetna Medicare Prime (PPO) 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. You can see complete 2022 Aetna Medicare Prime (PPO) H1608-004 Formulary here.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	$0	$15
Tier 2	$10	$20
Tier 3	$47	$47
Tier 4	$100	$100
Tier 5	33%	33%

*Initial Coverage Phase and 30 day supply

2021 Aetna Medicare Prime (PPO) Summary of Benefits

*This will be updated with 2022 data when available.

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Additional Benefits

No

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Comprehensive Dental

Diagnostic services	$0 copay
Diagnostic services	$0 copay (Out-of-Network)
Endodontics	$0 copay
Endodontics	$0 copay (Out-of-Network)
Extractions	$0 copay
Extractions	$0 copay (Out-of-Network)
Non-routine services	$0 copay
Non-routine services	$0 copay (Out-of-Network)
Periodontics	$0 copay
Periodontics	$0 copay (Out-of-Network)
Prosthodontics, other oral/maxillofacial surgery, other services	$0 copay
Prosthodontics, other oral/maxillofacial surgery, other services	$0 copay (Out-of-Network)
Restorative services	$0 copay
Restorative services	$0 copay (Out-of-Network)

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Deductible

$0

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	$0-325 copay
Diagnostic radiology services (e.g., MRI)	45% coinsurance (Out-of-Network)
Diagnostic tests and procedures	$0-40 copay
Diagnostic tests and procedures	45% coinsurance (Out-of-Network)
Lab services	$0 copay
Lab services	45% coinsurance (Out-of-Network)
Outpatient x-rays	$15 copay
Outpatient x-rays	45% coinsurance (Out-of-Network)

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Doctor Visits

Primary	$10 copay per visit
Primary	45% coinsurance per visit (Out-of-Network)
Specialist	$40 copay per visit
Specialist	45% coinsurance per visit (Out-of-Network)

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Emergency care/Urgent Care

Emergency	$90 copay per visit (always covered)
Urgent care	$65 copay per visit (always covered)

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Foot Care (podiatry services)

Foot exams and treatment	$40 copay
Foot exams and treatment	45% coinsurance (Out-of-Network)
Routine foot care	Not covered

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Ground Ambulance

$350 copay
$350 copay (Out-of-Network)

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Hearing

Fitting/evaluation	$0 copay
Fitting/evaluation	45% coinsurance (Out-of-Network)
Hearing aids	$0 copay
Hearing aids	$0 copay (Out-of-Network)
Hearing exam	$40 copay
Hearing exam	45% coinsurance (Out-of-Network)

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Inpatient Hospital Coverage

$390 per day for days 1 through 5 $0 per day for days 6 through 90
45% per stay (Out-of-Network)

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Medical Equipment/Supplies

Diabetes supplies	0-20% coinsurance per item
Diabetes supplies	0-20% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen)	20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen)	20% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item (Out-of-Network)

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Medicare Part B Drugs

Chemotherapy	20% coinsurance
Chemotherapy	45% coinsurance (Out-of-Network)
Other Part B drugs	20% coinsurance
Other Part B drugs	45% coinsurance (Out-of-Network)

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Mental Health Services

Inpatient hospital - psychiatric	$370 per day for days 1 through 5 $0 per day for days 6 through 90
Inpatient hospital - psychiatric	45% per stay (Out-of-Network)
Outpatient group therapy visit	$40 copay
Outpatient group therapy visit	45% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$40 copay
Outpatient group therapy visit with a psychiatrist	45% coinsurance (Out-of-Network)
Outpatient individual therapy visit	$40 copay
Outpatient individual therapy visit	45% coinsurance (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$40 copay
Outpatient individual therapy visit with a psychiatrist	45% coinsurance (Out-of-Network)

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MOOP

$11,300 In and Out-of-network $5,400 In-network

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Option

No

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Optional supplemental benefits

No

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Outpatient Hospital Coverage

$0-400 copay per visit
45% coinsurance per visit (Out-of-Network)

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Preventive Care

$0 copay
0-45% coinsurance (Out-of-Network)

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Preventive Dental

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

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Rehabilitation Services

Occupational therapy visit	$40 copay
Occupational therapy visit	45% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit	$40 copay
Physical therapy and speech and language therapy visit	45% coinsurance (Out-of-Network)

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Skilled Nursing Facility

$0 per day for days 1 through 20 $184 per day for days 21 through 100
45% per day for days 1 through 100 (Out-of-Network)

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Transportation

Not covered

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Vision

Contact lenses	$0 copay
Contact lenses	$0 copay (Out-of-Network)
Eyeglass frames	$0 copay
Eyeglass frames	$0 copay (Out-of-Network)
Eyeglass lenses	$0 copay
Eyeglass lenses	$0 copay (Out-of-Network)
Eyeglasses (frames and lenses)	$0 copay
Eyeglasses (frames and lenses)	$0 copay (Out-of-Network)
Other	$40 copay
Other	45% coinsurance (Out-of-Network)
Routine eye exam	$0 copay
Routine eye exam	45% coinsurance (Out-of-Network)
Upgrades	$0 copay
Upgrades	$0 copay (Out-of-Network)

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Wellness Programs (e.g. fitness nursing hotline)

Covered

CMS Star Ratings for Aetna Medicare Prime (PPO) H1608

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with Health Plan

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

Health Plan Customer Service Rating for Aetna Medicare Prime (PPO)

Aetna Medicare Prime (PPO) Drug Plan Customer Service Ratings

Ratings For Member Complaints and Changes in the Drug Plans Performance

Member Experience with the Drug Plan

Drug Safety and Accuracy of Drug Pricing

Ready to Enroll?

Click Here

Or Call
1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

Coverage Area for Aetna Medicare Prime (PPO)

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Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, 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 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.