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Aetna Medicare Value (PPO) (H5521-086-0)

Aetna Medicare Value PPO H5521-086-0 is a popular Aetna Medicare Advantage plan in Illinois. Available for people living in select counties in the state, this PPO plan features a variety of benefits in addition to the coverage offered under Original Medicare.

The Centers for Medicare and Medicaid Services (CMS) rates Medicare Advantage plans on a scale of 1 to 5 stars, with 5 being the highest score. Plans are rated using various categories. CMS then gives the health plan an overall star rating, along with a separate star rating for the drug portion if applicable.

This MA plan from Aetna has an overall rating of 4 stars from CMS in 2021. The drug plan portion has a rating of 3.5 stars.

 

Plan Basics

Aetna Medicare Value PPO H5521-086-0 is a PPO plan. 

PPO stands for preferred provider organization. These plans typically do not require you to have a primary care doctor or a referral to see a specialist. PPOs also tend to cover care from in-network and out-of-network providers, though costs are more likely to be lower if you stay in the plan’s network of preferred providers. A PPO plan may or may not cover prescription drugs. If it doesn’t, you cannot join a standalone Part D plan and won’t have drug coverage.

With this Medicare Advantage PPO plan from Aetna Medicare, you don’t need a referral to see a specialist. And you can see providers in or out of the plan’s network, but you’ll spend less out of pocket on in-network providers. 

Some services may require pre-authorization, meaning Aetna Medicare may need to approve of the service first.

As a Medicare Advantage plan, the Aetna Medicare Value PPO H5521-086-0 plan covers everything that Original Medicare covers. That’s by law. Beyond these basic requirements, this MA plan from Aetna covers a broader range of benefits than you’ll find under Original Medicare. 

This plan covers prescription drugs. There may be a separate drug deductible and cost sharing for this coverage. Refer to plan details for specifics on tiers, drug pricing and more.

This plan does not cover prescription drugs.

Below, we’ve outlined the costs and coverage of the Aetna Medicare Value Plan. Scroll down to the bottom for a complete table of costs for this MA health plan.

Basic Costs

In-Network Out-of-Network
Monthly premium $0
Annual deductible $0
Out-of-pocket maximum $3,950 $8,250

The monthly premium for the Aetna Medicare Value PPO H5521-086-0 plan is $0. You will also be responsible for your premiums under Original Medicare, typically just Part B for most people, unless you did not pay enough into Medicare through your paycheck withholdings and taxes. 

This plan also has a $0 deductible.

Medicare Advantage plans cap out-of-pocket expenses for the year. With the Aetna Medicare Value PPO H5521-086-0 plan, you’ll have a cap of $3,950 for in-network services and $8,250 for out-of-network care. 

Once you spend this amount out of pocket, Aetna Medicare will pay for your remaining covered services without any cost sharing — i.e., at 100%. 

Copays, coinsurance and deductibles typically count towards the Medicare Advantage out-of-pocket limit. Premiums and prescription drug costs typically do not count towards the cap.

Hospital Coverage (Medicare Part A)

In-Network Out-of-Network
Hospital day 1-7 $300 per day 50%
Hospital day 8+ $0 50%
Skilled nursing facility day 1-20 $0 50%
Skilled nursing facility day 21-100 $184 per day 50%
Inpatient mental health care $1,871 per stay 50%

Aetna Medicare Value PPO H5521-086-0 covers the same hospital and skilled nursing facility services as Original Medicare. But you may pay less out of pocket for these services thanks to how the plan covers Part A care. Medicare Part A is hospital and skilled nursing facility coverage.

For hospital care, you’ll have a copay of $300 per day for days 1 through 7. For days 8 through 90, you’ll pay $0 with the Aetna Medicare Value PPO plan. This plan covers an unlimited number of hospital days..

For skilled nursing facility (SNF) care, this Medicare Advantage plan from Aetna has a copay of $0 per day for days 1 through 20. From days 21 through 100, you pay $184 per day. Beyond that, you’ll pay the full cost of SNF care.

Medical Coverage (Medicare Part B)

In-Network Out-of-Network
Primary care doctor $0 $25
Specialist $35 $50
Preventive care $0 50%
Chiropractor $35 50%
Outpatient Mental Healthcare (Therapy, Psychiatry) $40 50%
Outpatient Hospital Services $0 to $400 50%
Ambulatory surgery center $400 50%
Emergency care in the U.S. $90 $90
Urgent care in the U.S. $65 $65
Ground ambulance $300 $300
Physical therapy $40 $50
Diagnostic tests & procedures $0 – $75 50%
Diagnostic radiology $200 50%
Lab services $20 $30
X-rays $15 50%
Medicare Part B drugs 20% 20%

Medicare Part B covers outpatient services. Think doctor’s visits, routine checkups, outpatient surgery, flu shots, ambulance rides and other general medicare care. The Aetna Medicare Value PPO H5521-086-0 plan covers everything that Original Medicare covers but at different cost sharing amounts.

Under Original Medicare, you’ll pay 20% of the cost of Part B services. And there’s no cap on that amount, which means you’ll pay that 20% no matter how high it gets. Medicare Advantage plans, like this one from Aetna, cap these costs and also include different cost sharing in the first place.

For example, this MA plan from Aetna Medicare has a $0 copay for in-network primary care visits and charges $35 for in-network specialists. And because this plan is a PPO plan, you have greater flexibility in the kinds of providers you see.

As a reminder, PPO plans tend to cover in-network and out-of-network services, though costs are typically lower with in-network providers. HMO plans may not cover care that you get outside of the plan’s network.

The Aetna Medicare Value PPO H5521-086-0 plan also covers a variety of preventive medical services at $0 for in-network care. These may include:

  • Certain cancer screenings
  • Cardiovascular disease screenings
  • Tobacco use cessation & counseling
  • Depression screenings
  • Preventive vaccines (like flu and shingles)
  • Nutrition therapy services
  • & more

You may pay more out of pocket for non-network care under a PPO plan. With an HMO plan, non-network care may not be covered at all.

As a reminder, some covered benefits with the Aetna Medicare Value PPO plan may require pre-authorization. Always check your plan details carefully to see specific costs for the services you’ll need.

Other Health Benefits

In-Network Out-of-Network
Preventive dental services $0 30%
Dental X-Rays $0 30%
Routine eye exams $0 $50
Glasses or contacts

$100 per year

Routine hearing exams $0 $50
Hearing aids

Up to $500 per year

Original Medicare does not cover all of the medical care that you’ll need as you get older. Notably missing is coverage for prescription drugs, dental and vision benefits, hearing aids and exams, chiropractic services and routine foot care, among others.

Aetna Medicare Value PPO H5521-086-0 covers some of these and other benefits in addition to the standard benefits covered by Original Medicare. Added benefits under this Medicare Advantage plan from Aetna Medicare include:

  • Routine and comprehensive dental
  • Routine eye exams
  • A credit for glasses and/or contact lenses
  • Routine hearing exams
  • Hearing aids up to a specific dollar limit

Always check plan details for specifics about additional medical benefits offered by Medicare Advantage plans.

Medicare Advantage plans may include additional benefits not described above, such as access to fitness memberships, telehealth, nurse phone lines, coverage for non-medical services, and more. These benefits vary by plan.

For specific info on these and other covered care and services, check with the Summary of Benefits for this Medicare Advantage plan from Aetna.

Prescription Drug Coverage

30-day Supply 
(retail & mail-order)
90-day Supply
(retail & mail-order) 
Tier 1: Preferred Generic

$0 preferred / $15 standard

$0 preferred / $45 standard

Tier 2: Generic

$5 preferred / $20 standard

$10 preferred / $60 standard

Tier 3: Preferred Brand $47 $141
Tier 4: Non-preferred Drug $100 $300
Tier 5: Specialty 33% Not covered

The Aetna Medicare Value PPO H5521-086-0 plan covers prescription drugs.  There’s no separate premium or annual deductible for this coverage. Tier 1 drugs have $0 cost-sharing for preferred generics if you get them at a preferred pharmacy.

How much you pay out of pocket for your medication depends on the drug tier. Like other Medicare Advantage plans, this MA plan with drug coverage from Aetna covers prescriptions at different tiers. Preferred generics cost less while specialty drugs (tier 5) tend to cost the most. 

If you fall into the Part D coverage gap — also known as the “donut hole” — then you’ll be responsible for 25% of the cost of your medications until you hit the out-of-pocket spending threshold for the year. 

The initial coverage limit with this Aetna Medicare Value PPO plan is $4,130 in 2021. That amount comes from:

  • What you pay at the pharmacy counter out of pocket
  • What your drug plan pays for the drug

Once you and your plan’s combined spending reaches the initial coverage limit, you’ll be in the donut hole until spending hits $6,550 in 2021. While you’re in the donut hole, you’ll pay no more than 25% of the cost of your drugs. 

But with this Aetna Medicare PPO plan, you get a bit of extra help paying for drugs in the donut hole. 

That’s because 30-day supplies of tier 1 drugs require a $0 copay at preferred pharmacies ($15 for standard), and 30-day supplies of tier 2 drugs require only a $5 copay at preferred locations ($20 for standard). All other tiers have the standard 25% cost sharing.

While you’re in the Part D coverage gap, what you pay out of pocket and about 70% of the cost of brand name drugs count towards your total out-of-pocket spending, which will help you get out of the gap faster. 

Once that happens, the plan’s catastrophic Part D coverage level kicks in. At this point, the Aetna Medicare Value PPO plan charges the greater of:

  • 5% or $3.70 for generic drugs in 2021
  • 5% or $9.20 for brand name drugs in 2021

Plan Costs for Aetna Medicare Value PPO H5521-086-0

Plan Costs for Aetna Medicare Value PPO H5521-086-0
In-Network Out-of-Network
Monthly premium $0
Annual deductible $0
Out-of-pocket maximum $3,950 $8,250
Part A Costs

Hospital day 1-7

$300 per day 50%

Hospital day 8+

$0 50%

Skilled nursing facility day 1-20

$0 50%

Skilled nursing facility day 21-100

$184 per day 50%

Inpatient mental health care

$1,871 per stay 50%
Medical Costs

Primary care doctor

$0 $25

Specialist

$35 $50

Preventive care

$0 50%

Chiropractor

$20 50%

Mental Healthcare (Therapy, Psychiatry)

$40 50%

Outpatient Hospital Services

$0 to $400 50%

Ambulatory surgery center

$400 50%

Emergency care in the U.S.

$90 $90

Urgent care in the U.S.

$65 $65

Ground ambulance

$300 $300

Physical therapy

$40 $50

Diagnostic tests & procedures

$0 to $75 50%

Diagnostic radiology

$200 50%

Lab services

$20 $30

X-rays

$15 50%

Medicare Part B drugs

20% 20%
Other Health Benefit Costs

Preventive dental services

$0 30%

Dental X-Rays

$0 30%

Routine eye exams

$0 $50

Glasses or contacts

$100 per year

Routine hearing exams

$0 $50

Hearing aids

Up to $500 per year
Prescription Drug Costs
(Network restrictions may apply)

Annual deductible

$0

Initial coverage limit

$4,130

Out-of-pocket threshold

$6,550
30-day Supply
(retail & mail-order)
90-day Supply
(retail & mail-order) 

Tier 1: Preferred/ Generic

$0 preferred /$15 standard $0 preferred/$45 standard

Tier 2: Generic

$5 preferred / $20 standard

$10 preferred / $60 standard

Tier 3: Preferred Brand

$47 $141

Tier 4: Non-preferred Drug

$100 $300

Tier 5: Specialty

33% Not covered

Donut hole coverage

30-day supply for tier 1: $0 preferred / $15 standard 30-day supply for tier 2: $5 preferred / $20 standard
25% of the cost for tiers 3, 4 and 5

Catastrophic drug coverage

Greater of 5% or $3.70 for generics Greater of 5% or $9.20 for brand name