| 2020 Medicare Advantage Plan Details | |||||
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| Medicare Plan Name: | Aetna Medicare Freedom Plan (PPO) | ||||
| Location: | Autauga, Alabama | ||||
| Plan ID: | H5521 – 224 – 0 | ||||
| Member Services: | 1-800-282-5366 TTY users 711 | ||||
| — Enrollment Options — | |||||
| Medicare Contact Information: | 1-800-MEDICARE (1-800-633-4227) TTY users 1-877-486-2048 |
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| — Medicare Plan Features — | |||||
| Monthly Premium: | $0.00 (see Plan Premium Details below) | ||||
| Annual Deductible: | $200 (Tier 1 and 2 excluded from the Deductible.) | ||||
| Annual Initial Coverage Limit (ICL): | $4,020 | ||||
| Health Plan Type: | Local PPO | ||||
| Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $5,700 | ||||
| Additional Gap Coverage? | Yes, some additional gap coverage. | ||||
| Total Number of Formulary Drugs: | 3,774 drugs | ||||
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This plan has 5 drug tiers.
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| Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
| • Preferred Pharmacy Cost-Sharing during initial coverage phase: |
$0.00 | $10.00 | $47.00 | $100.00 | 29% |
| • Number of Drugs per Tier: |
330 | 573 | 918 | 1313 | 640 |
| Plan’s Pharmacy Search: | |||||
| Plan Offers Mail Order? | Yes | ||||
| Number of Members enrolled in this plan in Autauga, Alabama: | 47 members | ||||
| Number of Members enrolled in this plan in Alabama: | 393 members | ||||
| Number of Members enrolled in this plan in (H5521 – 224): | 420 members | ||||
| Plan’s Summary Star Rating: | 4.5 out of 5 Stars. | ||||
| • Customer Service Rating: | 5 out of 5 Stars. | ||||
| • Member Experience Rating: | 4 out of 5 Stars. | ||||
| • Drug Cost Accuracy Rating: | 4 out of 5 Stars. | ||||
| — Plan Premium Details — | |||||
| The Monthly Premium is Split as Follows: | Total Premium |
Part C Premium |
Part D Base Premium |
Part D Supplemental Premium |
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| $0.00 | $0.00 | $0.00 | $0.00 | ||
| Monthly Premium with Extra Help Low-Income Subsidy (LIS): | 100% Subsidy |
75% Subsidy |
50% Subsidy |
25% Subsidy |
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| Monthly Part D Premium with LIS: | $0.00 | $0.00 | $0.00 | $0.00 | |
| Total Monthly Premium with LIS (Parts C & D): | $0.00 | $0.00 | $0.00 | $0.00 | |
