| 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 | ||||
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: | http://www.aetnamedicare.com/findpharmacy | ||||
| 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 | |
| — Plan Health Benefits — | |||||
| ** Base Plan ** | |||||
| Premium | Total monthly premium: $0.00 | ||||
| Health plan premium: $0.00 | |||||
| Drug plan premium: $0.00 | |||||
| Standard Part B premium: $135.50 | |||||
| Part B premium reduction: No | |||||
| Deductible | Health plan deductible: $0 | ||||
| Drug plan deductible: $200.00 | |||||
| Estimated yearly costs | Estimated total yearly costs for care: $3,870.00 | ||||
| Out-of-pocket max | Out-of-pocket max: $10,000 In and Out-of-network $5,700 In-network | ||||
| Doctor services | Primary doctor visit: In-network: $5 per visit Out-of-network: $20 per visit | ||||
| Specialist visit: In-network: $30 per visit Out-of-network: $40 per visit | |||||
| Tests, labs, & imaging | Diagnostic tests & procedures: In-network: $5-95 Out-of-network: 25% | ||||
| Lab services: In-network: $5-15 Out-of-network: 25% | |||||
| Diagnostic radiology services (like MRI): In-network: $5-200 Out-of-network: 25% | |||||
| Outpatient x-rays: In-network: $5-25 Out-of-network: 25% | |||||
| Emergency care: $90 per visit (always covered) | |||||
| Urgent care: $5-30 per visit (always covered) | |||||
| Hospital services | Inpatient hospital coverage: In-network: $225 per day for days 1 through 5 $0 per day for days 6 through 90 Out-of-network: 25% per stay | ||||
| Outpatient hospital coverage: In-network: $30-195 per visit Out-of-network: 25% per visit | |||||
| Skilled nursing facility | Skilled nursing facility: In-network: $0 per day for days 1 through 20 $160 per day for days 21 through 100 Out-of-network: 25% per stay | ||||
| Preventive services | Preventive services: In-network: $0 copay Out-of-network: $0 copay | ||||
| Ambulance | Ground ambulance: In-network: $250 Out-of-network: $250 | ||||
| Therapy services | Occupational therapy visit: In-network: $20 Out-of-network: $40 | ||||
| Physical therapy & speech & language therapy visit: In-network: $20 Out-of-network: $40 | |||||
| Mental health services | Outpatient group therapy with a psychiatrist: In-network: $30 Out-of-network: $40 | ||||
| Outpatient individual therapy with a psychiatrist: In-network: $30 Out-of-network: $40 | |||||
| Outpatient group therapy visit: In-network: $30 Out-of-network: $40 | |||||
| Outpatient individual therapy visit: In-network: $30 Out-of-network: $40 | |||||
| Opioid treatment services | Opioid treatment services: Covered | ||||
| Other services | Durable medical equipment (like wheelchairs & oxygen): In-network: 15% per item Out-of-network: 25% per item | ||||
| Prosthetics (like braces, artificial limbs): In-network: 15% per item Out-of-network: 25% per item | |||||
| Diabetes supplies: In-network: 0-20% per item Out-of-network: 0-20% per item | |||||
| Hearing | Hearing exam: In-network: $30 Out-of-network: $40 | ||||
| Fitting/evaluation: In-network: $30 Out-of-network: $40 | |||||
| Hearing aids – All types: In-network: $0 copay Out-of-network: $0 copay | |||||
| Preventive dental | Oral exam: In-network: $0 copay Out-of-network: $0 copay | ||||
| Cleaning: In-network: $0 copay Out-of-network: $0 copay | |||||
| Fluoride treatment: In-network: $0 copay Out-of-network: $0 copay | |||||
| Dental x-rays: In-network: $0 copay Out-of-network: $0 copay | |||||
| Comprehensive dental | Non-routine services: In-network: $0 copay Out-of-network: $0 copay | ||||
| Diagnostic services: In-network: $0 copay Out-of-network: $0 copay | |||||
| Restorative services: In-network: $0 copay Out-of-network: $0 copay | |||||
| Endodontics: In-network: $0 copay Out-of-network: $0 copay | |||||
| Periodontics: In-network: $0 copay Out-of-network: $0 copay | |||||
| Extractions: In-network: $0 copay Out-of-network: $0 copay | |||||
| Prosthodontics, other oral/maxillofacial surgery, other services: In-network: $0 copay Out-of-network: $0 copay | |||||
| Vision | Routine eye exam: In-network: $0 copay Out-of-network: $0 copay | ||||
| Contact lenses: In-network: $0 copay Out-of-network: $0 copay | |||||
| Eyeglasses (frames & lenses): In-network: $0 copay Out-of-network: $0 copay | |||||
| Eyeglass frames (only): In-network: $0 copay Out-of-network: $0 copay | |||||
| Eyeglass lenses (only): In-network: $0 copay Out-of-network: $0 copay | |||||
| Upgrades: In-network: $0 copay Out-of-network: $0 copay | |||||
| More benefits | Fitness benefit: Limited coverage | ||||
| Over the counter drug benefits: Limited coverage | |||||
| In-home support services: Not covered | |||||
| Home and bathroom safety devices: Not covered | |||||
| Meals for short duration: Limited coverage | |||||
| Annual physical exams: Limited coverage | |||||
| Telehealth: Not covered | |||||
| Part B drugs | Chemotherapy drugs: In-network: 20% Out-of-network: 25% | ||||
| Other Part B drugs: In-network: 20% Out-of-network: 25% | |||||
