2022 Allina Health Aetna Medicare Elite (PPO)

Allina Health Aetna Medicare Elite (PPO) H3219-004 is a 2022 Medicare Advantage Plan or Part-C by Allina Health Aetna Medicare available to residents in Minnesota. This plan includes additional prescription drug (Part-D) coverage. The Allina Health Aetna Medicare Elite (PPO) has a monthly premium of $152.00 and has an in-network maximum out-of-pocket limit of $2,800 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $2,800 out-of-pocket. This can be a extremely nice safety net.

Allina Health Aetna Medicare Elite (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.

Allina Health Aetna Medicare works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Allina Health Aetna Medicare Elite (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Allina Health 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 Allina Health 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 Allina Health Aetna Medicare Medicare Advantage Plan Costs

Allina Health Aetna Medicare Elite (PPO) Part-C Premium

Allina Health Aetna Medicare charges a $152.00 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.

H3219-004 Part-D Deductible and Premium

Allina Health Aetna Medicare Elite (PPO) has a monthly drug premium of ($4.70) and a $0.00 drug deductible. This Allina Health Aetna Medicare plan offers a ($4.70) 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 $4.70 this Premium covers any enhanced plan benefits offered by Allina Health 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.

Allina Health 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 Allina Health Aetna Medicare plan does offer additional coverage through the gap.

H3219-004 Formulary or Drug Coverage

Allina Health Aetna Medicare Elite (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 Allina Health Aetna Medicare Elite (PPO) H3219-004 Formulary here.

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

*Initial Coverage Phase and 30 day supply

2021 Allina Health Aetna Medicare Elite (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)	$0-50 copay
Diagnostic radiology services (e.g., MRI)	20% coinsurance (Out-of-Network)
Diagnostic tests and procedures	$0 copay
Diagnostic tests and procedures	20% coinsurance (Out-of-Network)
Lab services	$0 copay
Lab services	20% coinsurance (Out-of-Network)
Outpatient x-rays	$0 copay
Outpatient x-rays	20% coinsurance (Out-of-Network)

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Doctor Visits

Primary	$0 copay
Primary	20% coinsurance per visit (Out-of-Network)
Specialist	$15 copay per visit
Specialist	$40 copay per visit (Out-of-Network)

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Emergency care/Urgent Care

Emergency	$90 copay per visit (always covered)
Urgent care	$0-15 copay per visit (always covered)

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Foot Care (podiatry services)

Foot exams and treatment	$15 copay
Foot exams and treatment	20% coinsurance (Out-of-Network)
Routine foot care	Not covered

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Ground Ambulance

$250 copay
$250 copay (Out-of-Network)

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Hearing

Fitting/evaluation	$0 copay
Fitting/evaluation	20% coinsurance (Out-of-Network)
Hearing aids	$0 copay
Hearing aids	$0 copay (Out-of-Network)
Hearing exam	$15 copay
Hearing exam	20% coinsurance (Out-of-Network)

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Inpatient Hospital Coverage

$250 per stay
20% 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	20% coinsurance (Out-of-Network)
Other Part B drugs	20% coinsurance
Other Part B drugs	20% coinsurance (Out-of-Network)

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Mental Health Services

Inpatient hospital - psychiatric	$250 per stay
Inpatient hospital - psychiatric	20% per stay (Out-of-Network)
Outpatient group therapy visit	$15 copay
Outpatient group therapy visit	$40 copay (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$15 copay
Outpatient group therapy visit with a psychiatrist	$40 copay (Out-of-Network)
Outpatient individual therapy visit	$15 copay
Outpatient individual therapy visit	$40 copay (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$15 copay
Outpatient individual therapy visit with a psychiatrist	$40 copay (Out-of-Network)

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MOOP

$5,500 In and Out-of-network $3,500 In-network

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Option

No

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Optional supplemental benefits

No

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Outpatient Hospital Coverage

$0-100 copay per visit
20% coinsurance per visit (Out-of-Network)

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Preventive Care

$0 copay
0-20% 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	$15 copay
Occupational therapy visit	20% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit	$15 copay
Physical therapy and speech and language therapy visit	20% coinsurance (Out-of-Network)

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Skilled Nursing Facility

$0 per day for days 1 through 20 $100 per day for days 21 through 100
20% per stay (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	$15 copay
Other	20% coinsurance (Out-of-Network)
Routine eye exam	$0 copay
Routine eye exam	20% 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 Allina Health Aetna Medicare Elite (PPO) H3219

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with Health Plan

Member Complaints and Changes in Allina Health Aetna Medicare Elite (PPO) Plans Performance

Health Plan Customer Service Rating for Allina Health Aetna Medicare Elite (PPO)

Allina Health Aetna Medicare Elite (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 Allina Health Aetna Medicare Elite (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.