Aetna Medicare Dual Signature Select (PPO D-SNP)
H5521 - 473 - 0
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Aetna Medicare Dual Signature Select (PPO D-SNP) is a Medicare Advantage Special Needs Plan by Aetna Medicare.
This page features plan details for 2024 Aetna Medicare Dual Signature Select (PPO D-SNP) H5521 – 473 – 0.
IMPORTANT: This page features the 2024 version of this plan. See the 2025 version using the link below:
No 2025 version found. You can use the location links below to find 2025 plans in your area.
Locations
Aetna Medicare Dual Signature Select (PPO D-SNP) is offered in the following locations.
Plan Overview
Aetna Medicare Dual Signature Select (PPO D-SNP) offers the following coverage and cost-sharing.
| Special Needs Plan Type: | Dual-Eligible |
| Conditions Covered: |
| Insurer: | Aetna Medicare |
| Health Plan Deductible: | $0.00 |
| MOOP: | $9,550 In and Out-of-network $5,400 In-network |
| Drugs Covered: | Yes |
Please Note:
- This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.
- Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.
Ready to sign up for Aetna Medicare Dual Signature Select (PPO D-SNP) ?
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 Dual Signature Select (PPO D-SNP) has a monthly premium of $27.70. 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 | $27.70 | $0.00 | $ |
- 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 Dual Signature Select (PPO D-SNP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $545.00 |
| Initial Coverage Limit: | $5,030.00 |
| Catastrophic Coverage Limit: | $8,000.00 |
| Drug Benefit Type: | Basic |
| Additional Gap Coverage: | No |
| 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 D | LIS Full |
|---|---|
| $27.70 | $0.00 |
Initial Coverage Phase
After you pay your $545.00 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.
30 Day
60 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 25% | 25% |
60 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 25% | 25% |
Gap Coverage Phase
30 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| Generic drugs | ||||
| Brand-name drugs |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| Generic drugs | ||||
| Brand-name drugs |
| 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.
Additional Benefits
Aetna Medicare Dual Signature Select (PPO D-SNP) also provides the following benefits.
| $0 |
| In-network | No |
| $9,550 In and Out-of-network $5,400 In-network |
| No |
| In-network | Yes, contact plan for further details |
| In-network | $0 or $0-225 copay per visit (Authorization is required.) (Referral is not required.) |
| out-of-network | 20% coinsurance per visit (Authorization is required.) (Referral is not required.) |
| In-network Primary | $0 copay (Not applicable.) (Not applicable.) |
| out-of-network Primary | $0 copay (Not applicable.) (Not applicable.) |
| In-network Specialist | $0 or $25 copay per visit (Authorization is not required.) (Referral is not required.) |
| out-of-network Specialist | $25 copay per visit (Authorization is not required.) (Referral is not required.) |
| In-network | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network | $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $0 or $120 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $0 or $15 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| In-network Diagnostic tests and procedures | $0 or $0-95 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic tests and procedures | 20% 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 | 40% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Diagnostic radiology services (e.g., MRI) | 0% or 0-20% coinsurance (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic radiology services (e.g., MRI) | 20% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Outpatient x-rays | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient x-rays | 40% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Hearing exam | $0 or $25 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing exam | $25 copay (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/evaluation | $0 copay (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.) |
| In-network Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Oral exam | $0 copay (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 Cleaning | $0 copay (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 treatment | $0 copay (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) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Non-routine services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Non-routine services | $0 copay (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 services | $0 copay (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 services | $0 copay (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 Endodontics | $0 copay (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 Periodontics | $0 copay (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 Extractions | $0 copay (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 services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Routine eye exam | $0 copay (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 Other | $0 copay (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.) |
| In-network Occupational therapy visit | $0 or $25 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Occupational therapy visit | $25 copay (Authorization is not required.) (Referral is not required.) |
| In-network Physical therapy and speech and language therapy visit | $0 or $25 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Physical therapy and speech and language therapy visit | $15 copay (Authorization is not required.) (Referral is not required.) |
| In-network | $0 or $290 copay (Not applicable.) (Not applicable.) |
| out-of-network | $290 copay (Not applicable.) (Not applicable.) |
| In-network | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Foot exams and treatment | $0 or $25 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Foot exams and treatment | $25 copay (Authorization is not required.) (Referral is not required.) |
| In-network Routine foot care | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Durable medical equipment (e.g., wheelchairs, oxygen) | 0% or 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Prosthetics (e.g., braces, artificial limbs) | 0% or 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Diabetes supplies | $0 copay (Authorization is required.) (Not applicable.) |
| out-of-network Diabetes supplies | 0-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| In-network Chemotherapy | 0% or 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Chemotherapy | 40% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Other Part B drugs | 0% or 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Other Part B drugs | 40% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Part B Insulin drugs | $0 or $35 copay (Authorization is required.) (Not applicable.) |
| out-of-network Part B Insulin drugs | 40% coinsurance (Authorization is required.) (Not applicable.) |
| In-network | $0 or $373 per day for days 1 through 7 $0 per day for days 8 through 90 (Authorization is required.) (Referral is not required.) |
| out-of-network | $373 per day for days 1 through 6 $0 per day for days 7 through 90 (Authorization is required.) (Referral is not required.) |
| In-network Inpatient hospital – psychiatric | $0 or $624 per day for days 1 through 3 $0 per day for days 4 through 90 (Authorization is required.) (Referral is not required.) |
| out-of-network Inpatient hospital – psychiatric | $312 per day for days 1 through 6 $0 per day for days 7 through 90 (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit with a psychiatrist | $0 or $40 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit with a psychiatrist | 40% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit with a psychiatrist | $0 or $40 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit with a psychiatrist | 40% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit | $0 or $40 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit | 40% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit | $0 or $40 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit | 40% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network | $0 per day for days 1 through 20 $0 or $203 per day for days 21 through 100 (Authorization is required.) (Referral is not required.) |
| out-of-network | $0 per day for days 1 through 20 $203 per day for days 21 through 100 (Authorization is required.) (Referral is not required.) |
Ready to sign up for Aetna Medicare Dual Signature Select (PPO D-SNP) ?
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