Aetna Copay For Specialist



Luckily, his health plan has some fixed costs and only requires $30 copays for visits to his regular doctor and $50 copays to see specialists like an orthopedist. (He also once paid a $150 copay the night he landed in the emergency room when his knee was so swollen he couldn’t bend it.). Your copay may be lower for PCP visits. A copay is a fixed dollar amount you pay at the time of a visit. Any network provider Visit any network doctor or specialist without a referral. Network doctors contract with Aetna to offer rates that are often lower than their regular fees. A specialist is a doctor who focuses only.


Aetna Medicare Prime (HMO-POS) H2663-015 is a 2020 Medicare Advantage Plan or Medicare Part-C plan by Aetna Medicare available to residents in Missouri. This plan includes additional Medicare prescription drug (Part-D) coverage. The Aetna Medicare Prime (HMO-POS) has a monthly premium of $- and has an in-network Maximum Out-of-Pocket limit of $2,600 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $2,600 out of pocket. This can be a extremely nice safety net.

Aetna Medicare Prime (HMO-POS) is a Local HMO. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your PCP will serve as your personal doctor to provide all of your basic healthcare services. If you require specialized care or a physician specialist, your primary care physician will make the arrangements and inform you where you can go in the network. You will need your PCPs okay, called a referral. Services received from an out-of-network provider are not typically covered by the plan.

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 Prime (HMO-POS) 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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2020 Aetna Medicare Medicare Advantage Plan Details

Name:
ID:
H2663-015
Provider:Aetna Medicare
Year:2020
Type: Local HMO
Monthly Premium C+D: $-
Part C Premium:$0.00
MOOP: $2,600
Part D (Drug) Premium:$0.00
Part D Supplemental Premium$0.00
Total Part D Premium:$0.00
Drug Deductible:$0.00
Tiers with No Deductible:0
Gap Coverage:Yes
Benchmark:not below the regional benchmark
Type of Medicare Health:Enhanced Alternative
Drug Benefit Type:Enhanced

Part-C Premium

Aetna Medicare plan charges a $0.00 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.


Part-D Deductible and Premium

Aetna

Aetna Medicare Prime (HMO-POS) has a monthly drug premium of $0.00 and a $0.00 drug deductible. This Aetna Medicare plan offers a $0.00 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 $0.00 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 $0.00. 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.


Premium Assistance

Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The Aetna Medicare Prime (HMO-POS) medicare insurance offers a $0.00 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $0.00 for 75% low income subsidy $0.00 for 50% and $0.00 for 25%.


Full LIS Premium:$0.00
75% LIS Premium:$0.00
50% LIS Premium:$0.00
25% LIS Premium:$0.00

Gap Coverage

In 2020 once you and your plan provider have spent $4020 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.


Aetna Medicare Drug Coverage and Formulary

A formulary is divided into tiers or levels of coverage based on the type or usage of your medication or benefit categories, according to drug costs. Each tier will have a defined out-of-pocket cost that you must pay before receiving the drug. You can see complete 2020 Aetna Medicare Prime (HMO-POS) H2663-015 Formulary here.


See the 2020 Aetna Medicare Formulary


2019 Plan Services

(*2020 Plan services will be added when available)



Health plan deductible


$0


Emergency care/Urgent care


Emergency$90 per visit (always covered)
Urgent care$65 per visit (always covered)

Does Aetna Require A Referral To See A Specialist


Diagnostic procedures/lab services/imaging


Diagnostic tests and proceduresOut-of-Network30%
Diagnostic tests and proceduresIn-Network$280 or 20%
Lab servicesOut-of-Network30%
Lab servicesIn-Network$0
Diagnostic radiology services (e.g., MRI)Out-of-Network30%
Diagnostic radiology services (e.g., MRI)In-Network$40-140
Outpatient x-raysOut-of-Network30%
Outpatient x-raysIn-Network$10


Hearing


Hearing examOut-of-Network30%
Hearing examIn-Network$40
Fitting/evaluationIn-Network$0 copay
Hearing aidsIn-Network$0 copay


Preventive dental


Oral examIn-Network$0 copay
CleaningIn-Network$0 copay
Fluoride treatmentNot covered
Dental x-ray(s)In-Network$0 copay


Comprehensive dental


Non-routine servicesNot covered
Diagnostic servicesNot covered
Restorative servicesIn-Network50%
EndodonticsIn-Network50%
PeriodonticsIn-Network50%
ExtractionsIn-Network50%
Prosthodontics, other oral/maxillofacial surgery, other servicesIn-Network50%


Vision


Routine eye examOut-of-Network30%
Routine eye examIn-Network$0 copay
OtherNot covered
Contact lensesIn-Network$0 copay
Eyeglasses (frames and lenses)In-Network$0 copay
Eyeglass framesIn-Network$0 copay
Eyeglass lensesIn-Network$0 copay
UpgradesIn-Network$0 copay


Mental health services


Inpatient hospital - psychiatricOut-of-Network30% per stay
Inpatient hospital - psychiatricIn-Network$250 per day for days 1 through 5
$0 per day for days 6 through 90
Outpatient group therapy visit with a psychiatristOut-of-Network30%
Outpatient group therapy visit with a psychiatristIn-Network$40
Outpatient individual therapy visit with a psychiatristOut-of-Network30%
Outpatient individual therapy visit with a psychiatristIn-Network$40
Outpatient group therapy visitOut-of-Network30%
Outpatient group therapy visitIn-Network$40
Outpatient individual therapy visitOut-of-Network30%
Outpatient individual therapy visitIn-Network$40


Skilled Nursing Facility


Out-of-Network30% per stay
In-Network$20 per day for days 1 through 20
$167 per day for days 21 through 100


Rehabilitation services


Occupational therapy visitOut-of-Network30%
Occupational therapy visitIn-Network$40
Physical therapy and speech and language therapy visitOut-of-Network30%
Physical therapy and speech and language therapy visitIn-Network$40


Ground ambulance


Out-of-Network$285
In-Network$285


Other health plan deductibles?


In-NetworkNo


Transportation


Not covered


Foot care (podiatry services)


Foot exams and treatmentOut-of-Network30%
Foot exams and treatmentIn-Network$40
Routine foot careOut-of-Network30%
Routine foot careIn-Network$40


Medical equipment/supplies


Durable medical equipment (e.g., wheelchairs, oxygen)Out-of-Network30% per item
Durable medical equipment (e.g., wheelchairs, oxygen)In-Network20% per item
Prosthetics (e.g., braces, artificial limbs)Out-of-Network30% per item
Prosthetics (e.g., braces, artificial limbs)In-Network20% per item
Diabetes suppliesOut-of-Network0-20% per item
Diabetes suppliesIn-Network0-20% per item


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


Covered


Medicare Part B drugs


ChemotherapyOut-of-Network30%
ChemotherapyIn-Network20%
Other Part B drugsOut-of-Network30%
Other Part B drugsIn-Network20%


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


$2,600 In-network


Optional supplemental benefits


No


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


In-NetworkNo


Inpatient hospital coverage


Out-of-Network30% per stay
In-Network$250 per day for days 1 through 5
$0 per day for days 6 through 90


Outpatient hospital coverage


Out-of-Network30% per visit
In-Network$280 per visit


Doctor visits


PrimaryOut-of-Network30% per visit
PrimaryIn-Network$0 copay
SpecialistOut-of-Network30% per visit
SpecialistIn-Network$40 per visit


Preventive care


Out-of-Network0-30%
In-Network$0 copay

Ratings for Aetna Medicare Prime (HMO-POS) H2663

2019 Overall Rating
Part C Summary Rating
Part D Summary Rating
Staying Healthy: Screenings, Tests, Vaccines
Managing Chronic (Long Term) Conditions
Member Experience with Health Plan
Complaints and Changes in Plans Performance
Health Plan Customer Service
Drug Plan Customer Service
Complaints and Changes in the Drug Plan
Member Experience with the Drug Plan
Drug Safety and Accuracy of Drug Pricing

Staying Healthy, Screening, Testing, & Vaccines

Total Preventative Rating
Breast Cancer Screening
Colorectal Cancer Screening
Annual Flu Vaccine
Improving Physical
Improving Mental Health
Monitoring Physical Activity
Adult BMI Assessment

Managing Chronic And Long Term Care for Older Adults

Total Rating
SNP Care Management
Medication Review
Functional Status Assessment
Pain Screening
Osteoporosis Management
Diabetes Care - Eye Exam
Diabetes Care - Kidney Disease
Diabetes Care - Blood Sugar
Rheumatoid Arthritis
Reducing Risk of Falling
Improving Bladder Control
Medication Reconciliation
Plan All-Cause Readmissions
Statin Therapy

Member Experience with Health Plan

Total Experience Rating
Getting Needed Care
Timely Care and Appointments
Customer Service
Health Care Quality
Rating of Health Plan
Care Coordination

Member Complaints and Changes in Aetna Medicare Prime (HMO-POS) Plans Performance

Total Rating
Complaints about Health Plan
Members Leaving the Plan
Health Plan Quality Improvement

Health Plan Customer Service Rating for Aetna Medicare Prime (HMO-POS)

Total Customer Service Rating
Timely Decisions About Appeals
Reviewing Appeals Decisions
Call Center, TTY, Foreign Language

Aetna Medicare Prime (HMO-POS) Drug Plan Customer Service ratings

Copay
Total Rating
Call Center, TTY, Foreign Language
Appeals Auto
Appeals Upheld

Ratings For Member Complaints and Changes in the Drug Plans Performance

Total Rating
Complaints about the Drug Plan
Members Choosing to Leave the Plan
Drug Plan Quality Improvement

Member Experience with the Drug Plan

Aetna Default Copay

Total Rating
Rating of Drug Plan
Getting Needed Prescription Drugs

Drug Safety and Accuracy of Drug Pricing

Total Rating
MPF Price Accuracy
Drug Adherence for Diabetes Medications
Drug Adherence for Hypertension (RAS antagonists)
Drug Adherence for Cholesterol (Statins)
MTM Program Completion Rate for CMR
Statin with Diabetes


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Aetna Copay For Specialist Card


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1-855-778-4180
Mon-Sat 8am-11pm EST
Sun 9am-6pm EST



How To Pay Aetna Copay

Coverage Area for Aetna Medicare Prime (HMO-POS)

(Click county to compare all available Advantage plans)

State:Missouri
County:Franklin, Jefferson, St. Charles, St. Louis, St. Louis City,

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Source: CMS.
Data as of September 4, 2019.
Star Rating as of October 10, 2019.
Plan Services are 2019 information as reference. 2020 information will be added when released.
Notes: Data are subject to change as contracts are finalized. For 2020, 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 2020 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.