Aetna Medicare Core Plan (PPO)

H5521 - 419 - 0
4 out of 5 stars (4 / 5)

aetna-medicare medicare provider logo

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

This page features plan details for 2024 Aetna Medicare Core Plan (PPO) H5521 – 419 – 0 available in Los Angeles County.

IMPORTANT: This page features the 2024 version of this plan. See the 2025 version using the link below:

Locations

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

Plan Overview

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

Insurer:Aetna Medicare
Health Plan Deductible:$0.00
MOOP:$8,900 In and Out-of-network
$3,900 In-network
Drugs Covered:Yes

Ready to sign up for Aetna Medicare Core Plan (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 Core Plan (PPO) has a monthly premium of $0.00. 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
$174.70 $0.00 $0.00 $0.00 $
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 Core Plan (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible:$0.00
Initial Coverage Limit:$5,030.00
Catastrophic Coverage Limit:$8,000.00
Drug Benefit Type:Enhanced Alternative
Additional Gap Coverage:Yes
Formulary Link: Formulary Link

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
$0.00$

Initial Coverage Phase

After you pay your $0.00 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 $5,030.00. Once you reach that amount, you will enter the next coverage phase.

Gap Coverage Phase

Tier Cost
All other tiers (Generic)25%
All other tiers (Brand-name)25%

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $8,000.00, 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 Core Plan (PPO) also provides the following benefits.

Health plan deductible

$0

Other health plan deductibles?

In-network No

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

$8,900 In and Out-of-network
$3,900 In-network

Optional supplemental benefits

No

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

In-network No

Outpatient hospital coverage

In-network $0-350 copay per visit (Authorization is required.) (Referral is not required.)
out-of-network 40% coinsurance per visit (Authorization is required.) (Referral is not required.)

Doctor visits

In-network Primary$0 copay (Not applicable.) (Not applicable.)
out-of-network Primary$15 copay per visit (Not applicable.) (Not applicable.)
In-network Specialist$30 copay per visit (Authorization is not required.) (Referral is not required.)
out-of-network Specialist$40 copay per visit (Authorization is not required.) (Referral is not required.)

Preventive care

In-network $0 copay (Authorization is not required.) (Referral is not required.)
out-of-network 0-40% coinsurance (Authorization is not required.) (Referral is not required.)

Emergency care/Urgent care

Emergency$120 copay per visit (always covered) (Not applicable.) (Not applicable.)
Urgent care$40 copay per visit (always covered) (Not applicable.) (Not applicable.)

Diagnostic procedures/lab services/imaging

In-network Diagnostic tests and procedures$0-40 copay (Authorization is required.) (Referral is not required.)
out-of-network Diagnostic tests and procedures40% coinsurance (Authorization is required.) (Referral is not required.)
In-network Lab services$0 copay (Authorization is required.) (Referral is not required.)
out-of-network Lab services$65 copay (Authorization is required.) (Referral is not required.)
In-network Diagnostic radiology services (e.g., MRI)$0-295 copay (Authorization is required.) (Referral is not required.)
out-of-network Diagnostic radiology services (e.g., MRI)40% coinsurance (Authorization is required.) (Referral is not required.)
In-network Outpatient x-rays$40 copay (Authorization is required.) (Referral is not required.)
out-of-network Outpatient x-rays40% coinsurance (Authorization is required.) (Referral is not required.)

Hearing

In-network Hearing exam$0 copay (Authorization is not required.) (Referral is not required.)
out-of-network Hearing exam40% coinsurance (Authorization is not required.) (Referral is not required.)
In-network Fitting/evaluation$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Fitting/evaluation40% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)
In-network Hearing aids$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Hearing aids$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)

Preventive dental

In-network Oral exam$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Oral exam20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)
In-network Cleaning$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Cleaning20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)
In-network Fluoride treatment$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Fluoride treatment20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)
In-network Dental x-ray(s)$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Dental x-ray(s)20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)

Comprehensive dental

In-network Non-routine services$0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Non-routine services20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Diagnostic services$0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Diagnostic services20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Restorative services$0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Restorative services20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Endodontics$0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Endodontics20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Periodontics$0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Periodontics20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Extractions$0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Extractions20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Prosthodontics, other oral/maxillofacial surgery, other services$0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Prosthodontics, other oral/maxillofacial surgery, other services20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)

Vision

In-network Routine eye exam$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Routine eye exam40% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)
In-network Other$0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.)
out-of-network Other40% coinsurance (There are no limits.) (Authorization is not required.) (Referral is not required.)
In-network Contact lenses$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Contact lenses$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
In-network Eyeglasses (frames and lenses)$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Eyeglasses (frames and lenses)$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
In-network Eyeglass frames$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Eyeglass frames$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
In-network Eyeglass lenses$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Eyeglass lenses$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
In-network Upgrades$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Upgrades$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)

Rehabilitation services

In-network Occupational therapy visit$40 copay (Authorization is not required.) (Referral is not required.)
out-of-network Occupational therapy visit40% coinsurance (Authorization is not required.) (Referral is not required.)
In-network Physical therapy and speech and language therapy visit$40 copay (Authorization is not required.) (Referral is not required.)
out-of-network Physical therapy and speech and language therapy visit40% coinsurance (Authorization is not required.) (Referral is not required.)

Ground ambulance

In-network $265 copay (Not applicable.) (Not applicable.)
out-of-network $265 copay (Not applicable.) (Not applicable.)

Transportation

Not covered (Not applicable.) (Not applicable.)

Foot care (podiatry services)

In-network Foot exams and treatment$40 copay (Authorization is not required.) (Referral is not required.)
out-of-network Foot exams and treatment40% coinsurance (Authorization is not required.) (Referral is not required.)
Routine foot careNot covered (Not applicable.) (Not applicable.)

Medical equipment/supplies

In-network Durable medical equipment (e.g., wheelchairs, oxygen)0-20% coinsurance per item (Authorization is required.) (Not applicable.)
out-of-network Durable medical equipment (e.g., wheelchairs, oxygen)40% coinsurance per item (Authorization is required.) (Not applicable.)
In-network Prosthetics (e.g., braces, artificial limbs)18% coinsurance per item (Authorization is required.) (Not applicable.)
out-of-network Prosthetics (e.g., braces, artificial limbs)40% coinsurance per item (Authorization is required.) (Not applicable.)
In-network Diabetes supplies0-20% coinsurance per item (Authorization is required.) (Not applicable.)
out-of-network Diabetes supplies0-20% coinsurance per item (Authorization is required.) (Not applicable.)

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

Covered (Authorization is not required.) (Referral is not required.)

Medicare Part B drugs

In-network Chemotherapy0-20% coinsurance (Authorization is required.) (Not applicable.)
out-of-network Chemotherapy40% coinsurance (Authorization is required.) (Not applicable.)
In-network Other Part B drugs0-20% coinsurance (Authorization is required.) (Not applicable.)
out-of-network Other Part B drugs40% coinsurance (Authorization is required.) (Not applicable.)
In-network Part B Insulin drugs$35 copay (Authorization is required.) (Not applicable.)
out-of-network Part B Insulin drugs40% coinsurance (Authorization is required.) (Not applicable.)

Inpatient hospital coverage

In-network $350 per day for days 1 through 4
$0 per day for days 5 through 90 (Authorization is required.) (Referral is not required.)
out-of-network 40% per stay (Authorization is required.) (Referral is not required.)

Mental health services

In-network Inpatient hospital – psychiatric$350 per day for days 1 through 4
$0 per day for days 5 through 90 (Authorization is required.) (Referral is not required.)
out-of-network Inpatient hospital – psychiatric40% per stay (Authorization is required.) (Referral is not required.)
In-network Outpatient group therapy visit with a psychiatrist$40 copay (Authorization is required.) (Referral is not required.)
out-of-network Outpatient group therapy visit with a psychiatrist40% coinsurance (Authorization is required.) (Referral is not required.)
In-network Outpatient individual therapy visit with a psychiatrist$40 copay (Authorization is required.) (Referral is not required.)
out-of-network Outpatient individual therapy visit with a psychiatrist40% coinsurance (Authorization is required.) (Referral is not required.)
In-network Outpatient group therapy visit$40 copay (Authorization is required.) (Referral is not required.)
out-of-network Outpatient group therapy visit40% coinsurance (Authorization is required.) (Referral is not required.)
In-network Outpatient individual therapy visit$40 copay (Authorization is required.) (Referral is not required.)
out-of-network Outpatient individual therapy visit40% coinsurance (Authorization is required.) (Referral is not required.)

Skilled Nursing Facility

In-network $10 per day for days 1 through 20
$203 per day for days 21 through 100 (Authorization is required.) (Referral is not required.)
out-of-network 40% per stay (Authorization is required.) (Referral is not required.)

Ready to sign up for Aetna Medicare Core Plan (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

Table of Contents