Allina Health Aetna Medicare Select (PPO) H3219-014-0 Plan Details
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*CMS rated this Allina Health Aetna Medicare plan (H3219-014-0) 4 (Good) out of 5 stars.
Allina Health Aetna Medicare Select (PPO) is a Medicare Advantage plan with a prescription drug plan. The 2025 Annual Enrollment period starts October 15. Plan benefits begin Janu
Allina Health Aetna Medicare Select Basic Details
Plan Basics | |
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Plan ID: | H3219-014-0 |
Plan Type: | PPO |
Plan Year: | 2025 |
Premium: | $61.00/mo Plus your Medicare Part B premium. |
Health Plan Deductible: | $0.00 |
Out-of-Pocket Maximum: | 4,150.00 /yr |
Part B Reduction: | $0.00/mo |
Drug Plan Benefit: | Enhanced, $250.00 deductible |
Supplemental Benefits: | Vision, Hearing |
Availability: | See List |
Insured By: | Allina Health Aetna Medicare |
Summary of Benefits |
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Allina Health Aetna Medicare Out-of-Pocket Costs
This Allina Health Aetna Medicare Part C plan has cost-sharing. These are costs you pay out-of-pocket when you use approved health services. The following table summarizes the most common in-network out-of-pocket costs in plan H3219-014-0.
NOTE: Certain preventive services are covered 100% by the plan as a Part B benefit.
Healthcare Service | Member Cost |
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Doctor Visits (In-Network) | |
Primary: | $0 Copay |
Specialist: | $35 Copay |
Preventive care: | $0 Copay |
Foot Care (In-Network) | |
Foot exams and treatment (Medicare-covered): | $35 Copay |
Routine foot care: | $35 Copay |
Chiropractic Care (In-Network) | |
Medicare-covered chiropractic care: | $20 Copay |
Routine chiropractic care: | Not Covered |
Emergency Care / Urgent Care | |
Emergency room care: | $140 Copay |
Urgent care: | $40 Copay |
Ground ambulance: | $375 Copay |
Inpatient hospital coverage: | $400.00 per stay |
Outpatient hospital coverage: | $275 Copay Prior Authorization Required |
Skilled Nursing Facility: | $10.00 per day for days 1 through 20 $214.00 per day for days 21 through 40 $0.00 per day for days 41 and beyond |
Optional supplemental benefits: | |
Mental Health Services (In-Network) | |
Outpatient individual therapy visit with a psychiatrist: | $35 Copay |
Outpatient group therapy visit with a psychiatrist: | $35 Copay |
Inpatient hospital - psychiatric: | $400.00 per stay |
Outpatient group therapy visit: | $35 Copay |
Outpatient individual therapy visit: | $0 |
Rehabilitation Services (In-Network) | |
Physical therapy and speech and language therapy visit: | $40 Copay |
Occupational therapy visit: | $40 Copay |
Medical Equipment / Supplies (In-Network) | |
Diabetes supplies: | 20% Coinsurance Prior Authorization Required |
Durable medical equipment (e.g., wheelchairs, oxygen): | 20% Coinsurance Prior Authorization Required |
Prosthetics (e.g., braces, artificial limbs): | 20% Coinsurance |
Diagnostic Procedures / Lab Services / Imaging (In-Network) | |
Diagnostic radiology services (e.g., MRI): | $125 Copay Prior Authorization Required |
Lab services: | $5 Copay Prior Authorization Required |
Outpatient x-rays: | $15 Copay Prior Authorization Required |
Diagnostic tests and procedures: | $30 Copay Prior Authorization Required |
Medicare Part B Drugs (In-Network) | |
Chemotherapy: | 20% Coinsurance |
Other Part B drugs (Medicare-covered) | 20% Coinsurance |
Feel free to download our Allina Health Aetna Medicare Select Summary of Benefits information.
Supplemental Benefits
The following is a summary of the supplemental benefits Allina Health Aetna Medicare includes with this plan:
Supplemental Healthcare Service | Member Cost |
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Preventive Dental | |
Oral exam (In-Network) | Not Covered |
Fluoride treatment (In-Network) | Not Covered |
Dental x-ray(s) (In-Network) | Not Covered |
Cleaning (In-Network) | Not Covered |
Comprehensive Dental | |
Periodontics (In-Network) | Not Covered |
Non-routine services (In-Network) | Not Covered |
Diagnostic services (In-Network) | Not Covered |
Extractions (In-Network) | Not Covered |
Endodontics (In-Network) | Not Covered |
Restorative services (In-Network) | Not Covered |
Prosthodontics, other oral/maxillofacial surgery, other services (In-Network) | Not Covered |
Hearing Aids | |
Fitting/evaluation (In-Network) | Covered Limits may apply |
Hearing aids (In-Network) | Not Covered |
Hearing exam (In-Network) | Covered Limits may apply |
Vision | Maximum vision benefit: | $2.00 Every three years |
Eyeglasses (frames and lenses) (In-Network) | Not Covered |
Routine eye exam (In-Network) | $0 Copay |
Contact lenses (In-Network) | Not Covered |
Prescription Drug Plan Costs & Benefits
Allina Health Aetna Medicare Select includes an enhanced benefit Medicare Part D plan (PDP). Enhanced plans offer greater coverage than basic plans, typically providing lower cost-sharing, broader drug coverage, and additional benefits, such as covering drugs not included in the standard formulary. These plans usually have higher premiums due to the extra coverage and flexibility they provide, but they cover a larger percentage of overall drug costs.
As of 2023, approximately 75% of people on Medicare are enrolled in enhanced plans.
Prescription Drug Plan Premium
Although the prescription drug plan (Part D) premium is bundled with the total plan cost, some plans have supplemental costs and/or offer low-income subsidy (LIS) assistance. LIS, also known as Extra Help, is a Social Security program that helps people with limited income and resources lower or cut Part D costs.
The following table outlines the premium details of this prescription drug plan.
Basic Part D Premium: | $47.70 |
Supplemental Part D Premium: | $0.00 |
Total Part D Premium: | $47.70 |
Low Income Premium Subsidy: | $50.63 |
Low Income Premium Subsidy CMS Pays: | $47.70 |
Low Income Subsidy Premium: | $0.00 |
If you would like more information about the Extra Help program, you can refer to the Social Security Extra Help page.
Prescription Drug Plan Deductible
The Medicare Part D annual deductible with this plan is $250.00. You must pay this amount at the pharmacy before Allina Health Aetna Medicare begins paying its share.
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, Allina Health Aetna Medicare Select has out-of-pocket costs you must pay when you pick up your prescriptions.
Drug Tier | Retail | Mail Order | Out of Network |
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Preferred Generic | $0.00 | $2.00 | $0.00 |
Generic* | $10.00 | $12.00 | $0.00 |
Preferred Brand* | 25.00% | 25.00% | 0.00% |
Non-Preferred Drug | 26.00% | 26.00% | 0.00% |
Specialty Tier | 30.00% | 30.00% | 0.00% |
*The Part D deductible does not apply. |
CMS 5-Star Rating Marks
Each year the Centers for Medicare & Medicaid Services (CMS) rates health plans (Part C) and drug plans (Part D) in several major categories using a 5-star rating system. These ratings are designed to help you understand the quality of care and service you can expect if you join Allina Health Aetna Medicare Select .
CMS Measure | Star Rating |
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2025 Overall Rating | |
Staying Healthy: Screenings, Tests, Vaccines | |
Managing Chronic (Long Term) Conditions | |
Member Experience with Health Plan | |
Complaints and Changes in Plans Performance | |
Health Plan Customer Service | |
Drug Plan Customer Service | |
Complaints and Changes in the Drug Plan | |
Member Experience with the Drug Plan | |
Drug Safety and Accuracy of Drug Pricing |
Plan Availability
Allina Health Aetna Medicare Select (H3219-014-0) is available in the following locations (click to open):
Additional Plan Options
The Medicare Part C program offers a myriad of HMO, PPO, and PFFS plan options, including these plans:
- H3219-008-0: Allina Health Aetna Medicare SmartFit ()
- H3219-013-0: Allina Health Aetna Medicare Signature ()
- H3219-012-0: Allina Health Aetna Medicare Essential ()
- H3219-014-0: Allina Health Aetna Medicare Select ()
- H3219-002-0: Allina Health Aetna Medicare Premier ()
- H3219-001-0: Allina Health Aetna Medicare Plus ()
- H3219-003-0: Allina Health Aetna Medicare Grand ()
If you are enrolled in a Part C plan with prescription drug coverage, you cannot be enrolled in a stand-alone Medicare Part D plan, regardless of your chosen insurance company.
You cannot be enrolled in a Part C health plan and simultaneously hold Medicare Supplement Insurance (Medigap). Medicare Supplement plans are only compatible with Medicare Parts A and B.
Contact Allina Health Aetna Medicare
Plan Website: | http://www.AllinaHealthAetnaMedicare.com |
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Formulary Information: | http://www.AllinaHealthAetnaMedicare.com/findpharmacy |
Pharmacy Information: | Allina Health Aetna Medicare Pharmacy Page |
Prospective Members: | (833)206-8764 |
TTY Users: | 711 |
If you qualify for Medicare benefits but have not yet enrolled or verified your enrollment status, you can do so on the Social Security Administration website. You can learn more about the Medicare Part C program on www.medicare.gov or call 1-800-MEDICARE.
Citations & References
- Allina Health Aetna Medicare, http://www.AllinaHealthAetnaMedicare.com, Last Accessed February 20, 2024
- Medicare.gov, "Your health plan options", Last Accessed February 20, 2024
- Medicare.gov, "How Original Medicare Works", Last Accessed February 19, 2024
- Medicare.gov, "Medicare & You Handbook", Last Accessed February 19, 2024
- Medicare.gov, "Your Medicare Coverage", Last Accessed April 11, 2023
- CMS.gov, Landscape Source Files, Last Accessed February 21, 2024
- CMS.gov, Medicare Part C & D Performance, Last Accessed February 21, 2024
- CMS.gov, Plan Benefits Package, Last Accessed February 21, 2024
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Baylor Scott & White Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, GlobalHealth, Health Care Service Corporation, Healthy Blue, HealthSun, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.