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Aetna Medicare Choice (PPO)

H5521 - 370 - 0
4.5 out of 5 stars (4.5 / 5)

aetna-medicare medicare provider logo

Aetna Medicare Choice (PPO) is a Medicare Advantage Plan by Aetna Medicare.

This page features plan details for 2025 Aetna Medicare Choice (PPO) H5521 – 370 – 0 available in Amador, El Dorado, Santa Cruz and Solano Counties.

Locations

Aetna Medicare Choice (PPO) is offered in the following locations.

Amador County, California
California
El Dorado County, California

Click to see more locations

Plan Overview

Aetna Medicare Choice (PPO) offers the following coverage and cost-sharing.

Insurer:Aetna Medicare
Health Plan Deductible:$500 annual deductible
MOOP:$8,950 In and Out-of-network
$5,500 In-network
Drugs Covered:Yes

Ready to sign up for Aetna Medicare Choice (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Premium Breakdown

Aetna Medicare Choice (PPO) has a monthly premium of $24.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.
Part B Part C Part D Part B Give Back Total
$185.00 $0.00 $24.00 $ $
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.
  • You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

Aetna Medicare Choice (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $590.00
Drug Out-Of-Pocket maximum: $2,000.00
Drug Benefit Type: Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part DLIS Full
$24.00$0.00

Initial Coverage Phase

After you pay your $590.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

Aetna Medicare Choice (PPO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

    • In-Network: No

Comprehensive Dental

  • Adjunctive General Services
    • In-Network: No Coins – 0.00 Copay (Limits Apply)
    • Out-of-Network: 50% Coins – No Copay (Limits Apply)
  • Endodontics
    • In-Network: No Coins – 0.00 Copay (Limits Apply)
    • Out-of-Network: 50% Coins – No Copay (Limits Apply)
  • Oral and Maxillofacial Surgery
    • In-Network: No Coins – 0.00 Copay (Limits Apply)
    • Out-of-Network: 50% Coins – No Copay (Limits Apply)
  • Periodontics
    • In-Network: No Coins – 0.00 Copay (Limits Apply)
    • Out-of-Network: 50% Coins – No Copay (Limits Apply)
  • Prosthodontics, fixed
    • In-Network: No Coins – 0.00 Copay (Limits Apply)
    • Out-of-Network: 50% Coins – No Copay (Limits Apply)
  • Prosthodontics, removable
    • In-Network: No Coins – 0.00 Copay (Limits Apply)
    • Out-of-Network: 50% Coins – No Copay (Limits Apply)
  • Restorative Services
    • In-Network: No Coins – 0.00 Copay (Limits Apply)
    • Out-of-Network: 50% Coins – No Copay (Limits Apply)

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – 0.00 Copay (Limits Apply)
    • Out-of-Network: 50% Coins – No Copay (Limits Apply)
  • Fluoride Treatment
    • In-Network: No Coins – 0.00 Copay (Limits Apply)
    • Out-of-Network: 50% Coins – No Copay (Limits Apply)
  • Oral Exams
    • In-Network: No Coins – 0.00 Copay (Limits Apply)
    • Out-of-Network: 50% Coins – No Copay (Limits Apply)
  • Other Diagnostic Dental Services
    • In-Network: No Coins – 0.00 Copay (Limits Apply)
    • Out-of-Network: 50% Coins – No Copay (Limits Apply)
  • Other Preventive Dental Services
    • In-Network: No Coins – 0.00 Copay (Limits Apply)
    • Out-of-Network: 50% Coins – No Copay (Limits Apply)
  • Prophylaxis (cleaning)
    • In-Network: No Coins – 0.00 Copay (Limits Apply)
    • Out-of-Network: 50% Coins – No Copay (Limits Apply)

Diagnostic procedures/lab services/imaging

  • Outpatient x-rays
    • Out-of-Network: 45% coinsurance (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • In-Network: $0-200 copay (Authorization Required)
    • Out-of-Network: 45% coinsurance (Authorization Required)
  • Lab services
    • Out-of-Network: $65 copay (Authorization Required)
  • Outpatient x-rays
    • In-Network: $0 copay (Authorization Required)
  • Diagnostic tests and procedures
    • In-Network: $0 copay (Authorization Required)
    • Out-of-Network: 45% coinsurance (Authorization Required)
  • Lab services
    • In-Network: $0 copay (Authorization Required)

Doctor visits

  • Specialist
    • Out-of-Network: $65 copay per visit
    • In-Network: $0-25 copay per visit
  • Primary
    • In-Network: $0 copay
    • Out-of-Network: $25 copay per visit

Emergency care/Urgent care

  • Urgent care
    • $40 copay per visit (always covered)
  • Emergency
    • $125 copay per visit (always covered)

Foot care (podiatry services)

  • Foot exams and treatment
    • In-Network: $40 copay
  • Routine foot care
    • Not covered
  • Foot exams and treatment
    • Out-of-Network: 45% coinsurance

Ground ambulance

    • Out-of-Network: $285 copay
    • In-Network: $285 copay

Health plan deductible

    • $500 annual deductible

Hearing

  • Hearing aids OTC
    • Not covered
  • Medicare-Covered Hearing Exam
    • In-Network: $0 copay
  • Hearing aids
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: $0 copay (Limits Apply)
  • Fitting/evaluation
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: 45% coinsurance (Limits Apply)
  • Medicare-Covered Hearing Exam
    • Out-of-Network: 45% coinsurance

Inpatient hospital coverage

    • In-Network: $205 per day for days 1 through 6
      $0 per day for days 7 through 90 (Authorization Required)
    • Out-of-Network: 40% per stay (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

    • $8,950 In and Out-of-network
      $5,500 In-network

Medical equipment/supplies

  • Diabetes supplies
    • In-Network: 0-20% coinsurance per item (Authorization Required)
    • Out-of-Network: 0-20% coinsurance per item (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • Out-of-Network: 45% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • Out-of-Network: 45% coinsurance per item (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • In-Network: 0-20% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • In-Network: 20% coinsurance per item (Authorization Required)

Medicare Part B drugs

  • Chemotherapy
    • In-Network: 0-20% coinsurance (Authorization Required)
    • Out-of-Network: 45% coinsurance (Authorization Required)
  • Other Part B drugs
    • In-Network: 0-20% coinsurance (Authorization Required)
    • Out-of-Network: 45% coinsurance (Authorization Required)

Mental health services

  • Outpatient group therapy visit with a psychiatrist
    • Out-of-Network: 45% coinsurance (Authorization Required)
  • Outpatient group therapy visit
    • Out-of-Network: 45% coinsurance (Authorization Required)
  • Outpatient individual therapy visit
    • Out-of-Network: 45% coinsurance (Authorization Required)
  • Outpatient individual therapy visit with a psychiatrist
    • In-Network: $40 copay (Authorization Required)
  • Inpatient hospital – psychiatric
    • In-Network: $205 per day for days 1 through 6
      $0 per day for days 7 through 90 (Authorization Required)
  • Outpatient individual therapy visit
    • In-Network: $40 copay (Authorization Required)
  • Inpatient hospital – psychiatric
    • Out-of-Network: 45% per stay (Authorization Required)
  • Outpatient group therapy visit
    • In-Network: $40 copay (Authorization Required)
  • Outpatient group therapy visit with a psychiatrist
    • In-Network: $40 copay (Authorization Required)
  • Outpatient individual therapy visit with a psychiatrist
    • Out-of-Network: 45% coinsurance (Authorization Required)

Optional supplemental benefits

    • No

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • In-Network: $0-295 copay per visit (Authorization Required)
    • Out-of-Network: 45% coinsurance per visit (Authorization Required)

Preventive care

    • In-Network: $0 copay
    • Out-of-Network: 0-45% coinsurance

Rehabilitation services

  • Occupational therapy visit
    • In-Network: $30 copay
    • Out-of-Network: 45% coinsurance
  • Physical therapy and speech and language therapy visit
    • In-Network: $30 copay
    • Out-of-Network: 45% coinsurance

Skilled Nursing Facility

    • In-Network: $10 per day for days 1 through 20
      $150 per day for days 21 through 100 (Authorization Required)
    • Out-of-Network: 38% per stay (Authorization Required)

Transportation

    • Not covered

Vision

  • Eyeglass lenses
    • Not covered
  • Eyeglasses (frames and lenses)
    • Not covered
  • Other
    • In-Network: $0 copay
  • Routine eye exam
    • Out-of-Network: 45% coinsurance (Limits Apply)
    • In-Network: $0 copay (Limits Apply)
  • Upgrades
    • Not covered
  • Contact lenses
    • Not covered
  • Eyeglass frames
    • Not covered
  • Other
    • Out-of-Network: 45% coinsurance

Wellness programs (e.g., fitness, nursing hotline)

    • Covered

Ready to sign up for Aetna Medicare Choice (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

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Get Help Enrolling

Get help enrolling in a Medicare Advantage or Medicare Prescription Drug Plan by calling a licensed insurance agent today.

Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint

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