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Allina Health Aetna Medicare Grand (PPO)

H3219 - 003 - 0
4 out of 5 stars (4 / 5)

Allina Health Aetna Medicare Grand (PPO) is a Medicare Advantage Plan by Allina Health Aetna Medicare.

This page features plan details for 2025 Allina Health Aetna Medicare Grand (PPO) H3219 – 003 – 0 available in Twin Cities Metro and Select MN Counties.

Locations

Allina Health Aetna Medicare Grand (PPO) is offered in the following locations.

Anoka County, Minnesota
Blue Earth County, Minnesota
Carver County, Minnesota

Click to see more locations

Plan Overview

Allina Health Aetna Medicare Grand (PPO) offers the following coverage and cost-sharing.

Insurer:Allina Health Aetna Medicare
Health Plan Deductible:$0
MOOP:$5,300 In and Out-of-network
$3,300 In-network
Drugs Covered:Yes

Ready to sign up for Allina Health Aetna Medicare Grand (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

Allina Health Aetna Medicare Grand (PPO) has a monthly premium of $66.00. 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 $44.90 $21.10 $ $
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

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

Drug Deductible: $0.00
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
$21.10$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 $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

Allina Health Aetna Medicare Grand (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: 20% Coins – No Copay (Limits Apply)
  • Endodontics
    • In-Network: No Coins – 0.00 Copay (Limits Apply)
    • Out-of-Network: 20% Coins – No Copay (Limits Apply)
  • Oral and Maxillofacial Surgery
    • In-Network: No Coins – 0.00 Copay (Limits Apply)
    • Out-of-Network: 20% Coins – No Copay (Limits Apply)
  • Periodontics
    • In-Network: No Coins – 0.00 Copay (Limits Apply)
    • Out-of-Network: 20% Coins – No Copay (Limits Apply)
  • Prosthodontics, fixed
    • In-Network: No Coins – 0.00 Copay (Limits Apply)
    • Out-of-Network: 20% Coins – No Copay (Limits Apply)
  • Prosthodontics, removable
    • In-Network: No Coins – 0.00 Copay (Limits Apply)
    • Out-of-Network: 20% Coins – No Copay (Limits Apply)
  • Restorative Services
    • In-Network: No Coins – 0.00 Copay (Limits Apply)
    • Out-of-Network: 20% Coins – No Copay (Limits Apply)

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – 0.00 Copay (Limits Apply)
    • Out-of-Network: 20% Coins – No Copay (Limits Apply)
  • Fluoride Treatment
    • In-Network: No Coins – 0.00 Copay (Limits Apply)
    • Out-of-Network: 20% Coins – No Copay (Limits Apply)
  • Oral Exams
    • In-Network: No Coins – 0.00 Copay (Limits Apply)
    • Out-of-Network: 20% Coins – No Copay (Limits Apply)
  • Other Diagnostic Dental Services
    • In-Network: No Coins – 0.00 Copay (Limits Apply)
    • Out-of-Network: 20% Coins – No Copay (Limits Apply)
  • Other Preventive Dental Services
    • In-Network: No Coins – 0.00 Copay (Limits Apply)
    • Out-of-Network: 20% Coins – No Copay (Limits Apply)
  • Prophylaxis (cleaning)
    • In-Network: No Coins – 0.00 Copay (Limits Apply)
    • Out-of-Network: 20% Coins – No Copay (Limits Apply)

Diagnostic procedures/lab services/imaging

  • Diagnostic radiology services (e.g., MRI)
    • Out-of-Network: $150 copay (Authorization Required)
  • Diagnostic tests and procedures
    • In-Network: $0-20 copay (Authorization Required)
  • Lab services
    • In-Network: $0 copay (Authorization Required)
  • Outpatient x-rays
    • Out-of-Network: $20 copay (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • In-Network: $0-75 copay (Authorization Required)
  • Lab services
    • Out-of-Network: $0 copay (Authorization Required)
  • Outpatient x-rays
    • In-Network: $15 copay (Authorization Required)
  • Diagnostic tests and procedures
    • Out-of-Network: $20 copay (Authorization Required)

Doctor visits

  • Primary
    • In-Network: $0 copay
  • Specialist
    • In-Network: $0-20 copay per visit
    • Out-of-Network: $40 copay per visit
  • Primary
    • Out-of-Network: $25 copay per visit

Emergency care/Urgent care

  • Urgent care
    • $20 copay per visit (always covered)
  • Emergency
    • $140 copay per visit (always covered)

Foot care (podiatry services)

  • Foot exams and treatment
    • In-Network: $20 copay
    • Out-of-Network: $40 copay
  • Routine foot care
    • In-Network: $20 copay (Limits Apply)

Ground ambulance

    • In-Network: $250 copay
    • Out-of-Network: $250 copay

Health plan deductible

    • $0

Hearing

  • Hearing aids
    • Out-of-Network: $0 copay (Limits Apply)
  • Hearing aids OTC
    • Not covered
  • Medicare-Covered Hearing Exam
    • In-Network: $20 copay
  • Fitting/evaluation
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: $40 copay (Limits Apply)
  • Hearing aids
    • In-Network: $0 copay (Limits Apply)
  • Medicare-Covered Hearing Exam
    • Out-of-Network: $40 copay

Inpatient hospital coverage

    • In-Network: $195 per stay (Authorization Required)
    • Out-of-Network: 25% per stay (Authorization Required)

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

    • $5,300 In and Out-of-network
      $3,300 In-network

Medical equipment/supplies

  • Prosthetics (e.g., braces, artificial limbs)
    • In-Network: 20% coinsurance per item (Authorization Required)
  • Diabetes supplies
    • Out-of-Network: 0-20% coinsurance per item (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • Out-of-Network: 25% coinsurance per item (Authorization Required)
  • Diabetes supplies
    • In-Network: 0-20% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • Out-of-Network: 25% coinsurance per item (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • In-Network: 0-20% coinsurance per item (Authorization Required)

Medicare Part B drugs

  • Chemotherapy
    • In-Network: 0-20% coinsurance (Authorization Required)
  • Other Part B drugs
    • In-Network: 0-20% coinsurance (Authorization Required)
  • Chemotherapy
    • Out-of-Network: 25% coinsurance (Authorization Required)
  • Other Part B drugs
    • Out-of-Network: 25% coinsurance (Authorization Required)

Mental health services

  • Outpatient group therapy visit
    • In-Network: $20 copay (Authorization Required)
  • Outpatient individual therapy visit
    • In-Network: $20 copay (Authorization Required)
  • Outpatient individual therapy visit with a psychiatrist
    • In-Network: $20 copay (Authorization Required)
  • Inpatient hospital – psychiatric
    • In-Network: $195 per stay (Authorization Required)
    • Out-of-Network: 25% per stay (Authorization Required)
  • Outpatient group therapy visit
    • Out-of-Network: $40 copay (Authorization Required)
  • Outpatient group therapy visit with a psychiatrist
    • Out-of-Network: $40 copay (Authorization Required)
    • In-Network: $20 copay (Authorization Required)
  • Outpatient individual therapy visit with a psychiatrist
    • Out-of-Network: $40 copay (Authorization Required)
  • Outpatient individual therapy visit
    • Out-of-Network: $40 copay (Authorization Required)

Optional supplemental benefits

    • No

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • Out-of-Network: $400 copay per visit (Authorization Required)
    • In-Network: $0-250 copay per visit (Authorization Required)

Preventive care

    • In-Network: $0 copay
    • Out-of-Network: 0-25% coinsurance

Rehabilitation services

  • Occupational therapy visit
    • In-Network: $20 copay
  • Physical therapy and speech and language therapy visit
    • Out-of-Network: $40 copay
    • In-Network: $20 copay
  • Occupational therapy visit
    • Out-of-Network: $40 copay

Skilled Nursing Facility

    • In-Network: $0 per day for days 1 through 20
      $214 per day for days 21 through 36
      $0 per day for days 37 through 100 (Authorization Required)
    • Out-of-Network: 25% per stay (Authorization Required)

Transportation

    • Not covered

Vision

  • Eyeglass lenses
    • In-Network: $0 copay (Limits Apply)
  • Other
    • In-Network: $0 copay
  • Upgrades
    • In-Network: $0 copay (Limits Apply)
  • Contact lenses
    • In-Network: $0 copay (Limits Apply)
  • Eyeglass frames
    • In-Network: $0 copay (Limits Apply)
  • Eyeglass lenses
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglasses (frames and lenses)
    • Out-of-Network: $0 copay (Limits Apply)
  • Routine eye exam
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: $20 copay (Limits Apply)
  • Upgrades
    • Out-of-Network: $0 copay (Limits Apply)
  • Contact lenses
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglasses (frames and lenses)
    • In-Network: $0 copay (Limits Apply)
  • Other
    • Out-of-Network: $20 copay
  • Eyeglass frames
    • Out-of-Network: $0 copay (Limits Apply)

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

    • Covered

Ready to sign up for Allina Health Aetna Medicare Grand (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

Need more information on Allina Health Aetna Medicare Grand (PPO)? See 2025 Allina Health Aetna Medicare Grand (PPO) at MedicareAdvantageRX.com.

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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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