Aetna Medicare Premier Plan for Palm Beach, FL

Aetna Medicare Premier Plan
Summary Rating:This Medicare drug plan has an average rating of 4.0
Part C Premium:
$35.00
Part D Deductible:$310.00
ICL:$0.00
Mail Order:No
Gap Coverage:No Gap Coverage
LIS:No
Formulary Drugs:3134
Plan ID:H5521-033
Plan Year:2014
Residents of:FL Residents
Plan Type:Local PPO
Summary of Benefits:

Medicare Advantage Plan Summary & Benefits

Aetna Medicare Premier Plan, FL Medicare Advantage PlanAetna Medicare Premier Plan (H5521-033), Preferred Provider Organization Advantage Plan, Palm Beach County, FL

Aetna Medicare Premier Plan is a Preferred Provider Organization (PPO) healthcare plan for seniors and other beneficiaries in Palm Beach County, FL with Medicare benefits. A Medicare Advantage PPO plan gives you freedom to choose which doctors, specialists, and hospitals you visit. You can lower your costs when you use network providers. Plus, predictable copayments and coinsurance make it easier for you to budget healthcare costs.

The plan information presented on this page is a summary, but not a complete description of available benefits. Comprehensive information about the plan benefits is available from your agent.

Summary of Benefits

The information on this page is a brief summary. We recommend that you download and print the Summary of Benefits PDF document for this 2014 health plan and read it thoroughly. Please Contact an Agent or the plan if you have unanswered questions.

Monthly Premium

The monthly premium for this health insurance plan in Palm Beach County is $35.00 plus your monthly Medicare Part B premium. Most Medicare beneficiaries pay the standard monthly Part B premium in addition to their MA or MAPD plan premium. However, some beneficiaries are required to pay slightly higher Part B and Medicare Part D premiums because of their income (over $85,000 per year for singles or $170,000 for married couples), or due to late enrollment penalties.

Part D Prescription Drug Plan Information

This plan includes prescription drug coverage. The formulary (00014429) has a total of 3,134 prescription medications.

If you have Part D assistance, your premium will be adjusted based on your percentage.

Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
  — Drugs per Tier:158951765132948
  — Cost-Sharing in ICP:$4.00$45.00$95.0025%$0.00

The Medicare Part D deductible with this health plan is $310.00. This is the amount you will pay until the plan begins to pay its portion.

Maximum Out of Pocket (MOOP) Benefit

The new healthcare law allows for a maximum limit of $6,700 on your out of pocket medical costs for 2014 Medicare Advantage plans. This amount is commonly called the plan MOOP (Maximum Out of Pocket). A plan's MOOP does not include your prescription drugs or the monthly premiums you pay for your health plan. Although the mandatory MOOP limit is $6,700, the Affordable Care Act law allows for a “Voluntary MOOP” that can be as low as $3,400. The MOOP on this plan is $6,700 .

Doctor Visits

Most Medicare health plans require you to make a co-payment (aka, copay) when you visit your primary care physician or a doctor. Here's how this plan works:

  • $10 co-payment for each visit to your primary care physician.
  • $45 co-payment for each visit to a specialist covered by Medicare.
  • 30% of the cost for each visit to your primary care physician.
  • 30% of the cost for each visit to a specialist covered by Medicare.

Urgent Care Doctor Visits

Urgent care is the delivery of ambulatory medical care outside of a hospital emergency department on a walk-in basis without a scheduled appointment. Here's how Urgent Care works with this plan:

  • $55 co-payment for urgent care treatment covered by Medicare.

Emergency Care

Emergency care is medical attention for patients with acute illnesses or injuries which require immediate medical attention. Here's how Emergency Care works with this plan:

  • $65 co-payment for emergency room treatments covered by Medicare.
  • Worldwide coverage.
  • If you are immediately admitted to the hospital you pay $0 for the emergency room treatment.

Ambulance Service

Most health plans do not cover transportation to and from medical services. The exception, of course, is when you have an emergency or when non-ambulatory. Here's how this plan covers ambulance service:

  • $300 co-payment for ambulance benefits covered by Medicare.
  • $300 co-payment for ambulance benefits covered by Medicare.

Inpatient Treatment (Hospital Stays)

A patient who is admitted to a hospital or clinic for treatment that requires at least one overnight stay is an inpatient. Most health plans have a tiered cost structure for inpatient treatment. Here's how this plan covers hospital stays:

  • There is no limit to the number of days covered by the plan per stay in the hospital.
  • For hospital stay covered by Medicares:
  • Days 1 - 6: $275 co-payment per day.
  • .
  • Days 7 - 90: $0 co-payment per day.
.
  • $0 co-payment for additional non-Medicare-covered hospital days.
  • 30% of the cost for each hospital stay covered by Medicare.
  • Diagnostic Services

    Diagnostic services include X-rays, diagnostic tests, lab services, and radiology services. Here's how this plan covers diagnostic services:

    • $10 to $45 co-payment for Medicare-covered lab services.
    • $10 to $45 co-payment for diagnostic procedures and tests covered by Medicare.
    • $10 to $45 co-payment for X-Rays covered by Medicare.
    • 20% of the cost for Medicare-covered diagnostic radiology services (not including X-rays).
    • 20% of the cost for therapeutic radiology treatments covered by Medicare.
    • If the physician provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $10 to $45 may apply.
    • 30% of the cost for therapeutic radiology treatments covered by Medicare.
    • 30% of the cost for Medicare-covered outpatient X-rays.
    • 30% of the cost for Medicare-covered diagnostic radiology services.
    • 30% of the cost for diagnostic procedures and tests covered by Medicare.
    • 30% of the cost for Medicare-covered lab services.

    Preventive Services

    Medicare covers a wide range of preventive services, including cardiovascular screenings, alcohol misuse screening and counseling, depression screen, and diabedes screening, to name just a few. Here's how this plan covers preventive services:

    • $0 co-payment for all preventive services covered by traditional Medicare at zero cost sharing. All additional preventive services approved by Medicare mid-year will be paid by the plan or by Medicare.
    • $0 co-payment for a supplemental annual physical exam.
    • 30% of the cost for preventive treatment covered by Medicare.
    • 30% of the cost for a supplemental annual physical exam.

    Skilled Nursing Facility

    Medicare covers skilled nursing care in a skilled nursing facility (SNF) under certain conditions for a limited time (no long-term care). Here's how this plan covers SNF services:

    • The plan will cover up to 100 days per benefit period.
    • Prior inpatient treatment (hospital stay) is not required.
    • For SNF stays:
    • Days 1 - 20: $25 co-payment per day.
    • .
    • Days 21 - 100: $152 co-payment per day.
    .
  • 30% of the cost for each Medicare-covered SNF stay.
  • Mental Health

    Medicare covers both inpatient and outpatient mental health care services. Here's how this plan covers mental health

    Outpatient:

    • $40 co-payment for each individual therapy visit covered by Medicare
    • $40 co-payment for each group therapy visit covered by Medicare
    • $40 co-payment for each individual therapy visit with a psychiatrist covered by Medicare.
    • $40 co-payment for each Medicare-covered group therapy visit with a psychiatrist.
    • $55 co-payment for partial hospitalization program services covered by Medicare.
    • 30% of the cost for Medicare-covered Mental Health visits with a psychiatrist.
    • 30% of the cost for Medicare-covered Mental Health visits.
    • 30% of the cost for partial hospitalization program services covered by Medicare.

    Inpatient:

    • You are allowed a maximum of 190 days of inpatient (hospitalized) psychiatric care in a lifetime. Inpatient services are applied to the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric care given in a general hospital.
    • For hospital stay covered by Medicares:
    • Days 1 - 5: $295 co-payment per day.
    • .
    • Days 6 - 90: $0 co-payment per day.
    .
  • The plan covers 60 lifetime reserve days. $0 co-payment per lifetime reserve day.
  • 30% of the cost for each hospital stay covered by Medicare.
  • Dental

    In general, Original Medicare does not cover routine dental care. Currently, Medicare will pay for dental services that are an integral part either of a covered procedure (e.g., reconstruction of the jaw following accidental injury), or for extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw. Here's how this plan covers dental care:

    • Preventive dental benefits, including cleanings, are not covered.
    • $45 co-payment for dental benefits covered by Medicare.
    • 30% of the cost for comprehensive dental benefits covered by Medicare

    Vision

    In general, Original Medicare does not cover routine vision care. Currently, Medicare will pay for Glaucoma screenigs, eye prostheses, Astigmatism-Correcting Intraocular Lenses, and A conventional IOL is covered when implanted following cataract surgery. Here's how this plan covers vision services:

    • $0 to $45 co-payment for exams covered by Medicare to diagnose and treat diseases and conditions of the eye including an annual glaucoma screening for people at risk.
    • $0 co-payment for up to 1 supplemental routine eye exam each year.
    • $0 co-payment for one pair of eyeglasses covered by Medicare (lenses and frames) or contact lenses after cataract surgery.
    • If the doctor provides you services in addition to eye exams separate cost sharing of $10 to $45 may apply.
    • 30% of the cost for eye exams covered by Medicare.
    • 30% of the cost for supplemental routine eye exams.
    • 30% of the cost for corrective lenses covered by Medicare.

    Hearing

    Medicare doesn't cover routine hearing exams, hearing aids, or exams for fitting hearing aids. Medicare covers diagnostic hearing and balance exams if your doctor or other health care provider orders these tests to see if you need medical treatment. Here's how this plan covers hearing services:

    • Hearing aids are not covered.
    • $45 co-payment for diagnostic hearing exams covered by Medicare.
    • $0 co-payment for up to 1 supplemental routine hearing exam each year.
    • 30% of the cost for diagnostic hearing exams covered by Medicare.
    • 30% of the cost for supplemental hearing exams.

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    This page was last updated on: 10/28/2013

    More Information

    About The Insurer Aetna Medicare

    Membership:

    • 18.459 million medical members
    • 13.670 million dental members
    • 8.820 million pharmacy members

    Health care networks:
    • More than 1 million health care professionals
    • More than 575,000 primary care doctors and specialists
    • More than 5,400 hospitals
    • A network of specialist physicians, recognized with Aexcel® designation, based on clinical performance and cost efficiency1 
    Products and programs: 
    • Aetna offers a broad range of insurance and employee benefits products.
    • The first national, full-service health insurer to offer a consumer-directed health plan, Aetna continues to lead the way with its Aetna HealthFund2 line of products, including HSA, HRA and RRA options.
    • Aetna offers a wide array of programs and services that help control rising employee benefits costs while striving to improve the quality of health care, such as case management; disease management and patient safety programs; integrated medical, dental, pharmaceutical, behavioral health and disability information.
    • Aetna provides members with access to convenient tools and easy-to-understand information that can help them make better-informed decisions about their health and financial wellbeing.
    National presence: 
    • Aetna provides benefits through employers in all 50 states, with products and services targeted specifically to small, mid-sized and large multi-site national employers.
    • Aetna also serves individuals and Medicare and Medicaid beneficiaries in certain markets.

    The summary (overall) rating for this plan is 4.0 out of 5 based on reviews from 938 user ratings from the previous year. For more information about the review process, visit http://cms.gov.