Aetna Choice® POS II Medical Plan Department of Defense Nonappropriated Fund Health Benefits Program Summary of Benefits effective January 1, 2021. Urgent care facility 100% after $40 copay 60% after deductible Ambulance 80% after deductible 80% after deductible 5 A primary care physician (PCP) can be an internist, pediatrician, family. Aetna Health, Inc. BASIC HMO COPAY PLAN 1 SCHEDULE OF BENEFITS HMO/FL SMGRP-BA-COP SOB-1 05/03 1 INDIVIDUAL LIFETIME MAXIMUM BENEFIT $2 Million Dollars $5,000 Single OUT-OF-POCKET MAXIMUM EXPENSE LIMITS $10,000 Family. Urgent Care $75 Copayment per visit. Aetna Choice® POS II – ASC Classic Plan PLAN DESIGN & BENEFITS ADMINISTERED BY AETNA LIFE INSURANCE COMPANY - SELF FUNDED Page 3 Non-Urgent Use of Urgent Care Provider Not Covered Not Covered Emergency Room 10% after $125 copay; after deductible Same as in-network care Copay waived if admitted Non-Emergency Care in an Emergency Room.
- Aetna Urgent Care Policy
- Aetna Choice Pos Ii Urgent Care Copay
- Aetna Copay Information
- Is Aetna Choice Pos Ii A Ppo
- Do I Need A Referral With Aetna Choice Pos Ii
THIS PLAN ENDS ON DECEMBER 31, 2020
With Aetna Choice POS II plan, you may select any physicians and hospitals in and outside the plan's network. Selecting this plan will give you the freedom to continue seeing your current doctor if your doctor isn't part of the Aetna Choice POS II network.
Keep in mind that if your physician is not part of the plan's network, you will have to pay more for each visit, submit a claim for reimbursement and/or pay for the entire visit. If your current doctor is not in the Aetna Choice II POS network, Aetna will work with you to transition your care to an Aetna network provider.
The Patient Protection and Affordable Care Act (also known as the Health Care Reform law) requires that you receive a Summary of Benefits and Coverage (SBC). The SBC is designed to help you understand and evaluate your health plan choices. Digital copies provided in the Resource section on this page. Paper copies are also available, free of charge, from the Postdoc Benefits Office by calling 650-724-9490.
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Aetna Medicare Choice II Plan (PPO) H3288-002 is a 2021 Medicare Advantage Plan or Medicare Part-C plan by Aetna Medicare available to residents in Texas. This plan includes additional Medicare prescription drug (Part-D) coverage. The Aetna Medicare Choice II Plan (PPO) has a monthly premium of $15.00 and has an in-network Maximum Out-of-Pocket limit of $7,550 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $7,550 out of pocket. This can be a extremely nice safety net.
Aetna Medicare Choice II Plan (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.
Aetna Medicare works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Aetna Medicare Choice II Plan (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Aetna Medicare and not Original Medicare. With Medicare Advantage Plans you are always covered for urgently needed and emergency care. Plus you receive all of the benefits of Original Medicare from Aetna Medicare except hospice care. Original Medicare still provides you with hospice care even if you sign up for a Medicare Advantage Plan.
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2021 Aetna Medicare Medicare Advantage Plan Costs
| Name: | |
|---|---|
| Plan ID: | H3288-002 |
| Provider: | Aetna Medicare |
| Year: | 2021 |
| Type: | Local PPO |
| Monthly Premium C+D: | $15.00 |
| Part C Premium: | $0 |
| MOOP: | $7,550 |
| Part D (Drug) Premium: | $15.00 |
| Part D Supplemental Premium | $0 |
| Total Part D Premium: | $15.00 |
| Drug Deductible: | $300.0 |
| Tiers with No Deductible: | 1 |
| Gap Coverage: | Yes |
| Benchmark: | not below the regional benchmark |
| Type of Medicare Health: | Enhanced Alternative |
| Drug Benefit Type: | Enhanced |
| Similar Plan: | H3288-003 |
Aetna Medicare Choice II Plan (PPO) Part-C Premium
Aetna Medicare plan charges a $0 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.
H3288-002 Part-D Deductible and Premium
Aetna Medicare Choice II Plan (PPO) has a monthly drug premium of $15.00 and a $300.0 drug deductible. This Aetna Medicare plan offers a $15.00 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 $0 this Premium covers any enhanced plan benefits offered by 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 $15.00. The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lower due to negative basic or supplemental premiums.
Aetna Medicare Gap Coverage
In 2021 once you and your plan provider have spent $4130 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 Aetna Medicare plan does offer additional coverage through the gap.
Premium Assistance
The Low Income Subsidy (LIS) helps people with Medicare pay for prescription drugs, and lowers the costs of Medicare prescription drug coverage. Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The Aetna Medicare Choice II Plan (PPO) medicare insurance offers a $0 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $3.70 for 75% low income subsidy $7.50 for 50% and $11.20 for 25%.
| Full LIS Premium: | $0 |
|---|---|
| 75% LIS Premium: | $3.70 |
| 50% LIS Premium: | $7.50 |
| 25% LIS Premium: | $11.20 |
H3288-002 Formulary or Drug Coverage
Aetna Medicare Choice II Plan (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.
2021 Aetna Medicare Choice II Plan (PPO) Summary of Benefits
Additional Benefits
| No |
|---|
Comprehensive Dental
| Diagnostic services | Not covered |
|---|---|
| Endodontics | 70% coinsurance (Out-of-Network) |
| Endodontics | 50% coinsurance |
| Extractions | 70% coinsurance (Out-of-Network) |
| Extractions | 50% coinsurance |
| Non-routine services | 50% coinsurance |
| Non-routine services | 70% coinsurance (Out-of-Network) |
| Periodontics | 50% coinsurance |
| Periodontics | 70% coinsurance (Out-of-Network) |
| Prosthodontics, other oral/maxillofacial surgery, other services | Not covered |
| Restorative services | 70% coinsurance (Out-of-Network) |
| Restorative services | 50% coinsurance |
Deductible
| $0 |
|---|
Diagnostic Tests and Procedures
| Diagnostic radiology services (e.g., MRI) | 40% coinsurance (Out-of-Network) |
|---|---|
| Diagnostic radiology services (e.g., MRI) | $0-325 copay |
| Diagnostic tests and procedures | $0-50 copay |
| Diagnostic tests and procedures | 40% coinsurance (Out-of-Network) |
| Lab services | $0 copay |
| Lab services | 40% coinsurance (Out-of-Network) |
| Outpatient x-rays | 40% coinsurance (Out-of-Network) |
| Outpatient x-rays | $35 copay |
Doctor Visits
| Primary | $0 copay |
|---|---|
| Primary | 40% coinsurance per visit (Out-of-Network) |
| Specialist | $35 copay per visit |
| Specialist | 40% coinsurance per visit (Out-of-Network) |
Emergency care/Urgent Care
Aetna Urgent Care Policy
| Emergency | $90 copay per visit (always covered) |
|---|---|
| Urgent care | $0-65 copay per visit (always covered) |
Foot Care (podiatry services)
| Foot exams and treatment | 40% coinsurance (Out-of-Network) |
|---|---|
| Foot exams and treatment | $35 copay |
| Routine foot care | Not covered |
Ground Ambulance
| $285 copay (Out-of-Network) |
|---|
| $285 copay |
Hearing
| Fitting/evaluation | Not covered |
|---|---|
| Hearing aids - inner ear | Not covered |
| Hearing aids - outer ear | Not covered |
| Hearing aids - over the ear | Not covered |
| Hearing exam | 40% coinsurance (Out-of-Network) |
| Hearing exam | $35 copay |
Inpatient Hospital Coverage
| $335 per day for days 1 through 6 $0 per day for days 7 through 90 |
|---|
| 40% per stay (Out-of-Network) |
Medical Equipment/Supplies
| Diabetes supplies | 0-20% coinsurance per item (Out-of-Network) |
|---|---|
| Diabetes supplies | 0-20% coinsurance per item |
| Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item |
| Durable medical equipment (e.g., wheelchairs, oxygen) | 40% coinsurance per item (Out-of-Network) |
| Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item |
| Prosthetics (e.g., braces, artificial limbs) | 40% coinsurance per item (Out-of-Network) |
Medicare Part B Drugs
| Chemotherapy | 40% coinsurance (Out-of-Network) |
|---|---|
| Chemotherapy | 20% coinsurance |
| Other Part B drugs | 40% coinsurance (Out-of-Network) |
| Other Part B drugs | 20% coinsurance |
Mental Health Services
| Inpatient hospital - psychiatric | $1,871 per stay |
|---|---|
| Inpatient hospital - psychiatric | 40% per stay (Out-of-Network) |
| Outpatient group therapy visit | $40 copay |
| Outpatient group therapy visit | 40% coinsurance (Out-of-Network) |
| Outpatient group therapy visit with a psychiatrist | 40% coinsurance (Out-of-Network) |
| Outpatient group therapy visit with a psychiatrist | $40 copay |
| Outpatient individual therapy visit | 40% coinsurance (Out-of-Network) |
| Outpatient individual therapy visit | $40 copay |
| Outpatient individual therapy visit with a psychiatrist | 40% coinsurance (Out-of-Network) |
| Outpatient individual therapy visit with a psychiatrist | $40 copay |
MOOP
| $11,300 In and Out-of-network $7,550 In-network |
|---|
Option
| No |
|---|
Optional supplemental benefits
| No |
|---|
Outpatient Hospital Coverage
| $0-275 copay per visit |
|---|
| 40% coinsurance per visit (Out-of-Network) |
Preventive Care
| 0-40% coinsurance (Out-of-Network) |
|---|
| $0 copay |
Preventive Dental
| Cleaning | $0 copay |
|---|---|
| Cleaning | 30% coinsurance (Out-of-Network) |
| Dental x-ray(s) | 30% coinsurance (Out-of-Network) |
| Dental x-ray(s) | $0 copay |
| Fluoride treatment | Not covered |
| Oral exam | $0 copay |
| Oral exam | 30% coinsurance (Out-of-Network) |
Rehabilitation Services
| Occupational therapy visit | 40% coinsurance (Out-of-Network) |
|---|---|
| Occupational therapy visit | $40 copay |
| Physical therapy and speech and language therapy visit | $40 copay |
| Physical therapy and speech and language therapy visit | 40% coinsurance (Out-of-Network) |
Skilled Nursing Facility
| 40% per stay (Out-of-Network) |
|---|
| $0 per day for days 1 through 20 $184 per day for days 21 through 100 |
Transportation
| Not covered |
|---|
Aetna Choice Pos Ii Urgent Care Copay
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 | 40% coinsurance (Out-of-Network) |
| Other | $35 copay |
| Routine eye exam | $0 copay |
| Routine eye exam | 40% coinsurance (Out-of-Network) |
| Upgrades | $0 copay |
| Upgrades | $0 copay (Out-of-Network) |
Aetna Copay Information
Wellness Programs (e.g. fitness nursing hotline)
Is Aetna Choice Pos Ii A Ppo
| Covered |
|---|
Ready to Enroll?
Or Call
1-855-778-4180
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Sun 9am-6pm EST
Coverage Area for Aetna Medicare Choice II Plan (PPO)
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Do I Need A Referral With Aetna Choice Pos Ii
Source: CMS.
Data as of September 9, 2020.
Notes: Data are subject to change as contracts are finalized. For 2021, 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 2021 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.