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Aetna Medicare Signature Extra (PPO) H5521-759 - H5521-759-000
$0.00
Monthly Premium
Aetna Medicare Signature Extra (PPO) H5521-759 is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna®
Plan ID: H5521-759-000
** Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
If you have Medicare in North Dakota, you may want to review your coverage options. Medicare Advantage plans cover services that aren’t covered by Original Medicare (Part A and Part B).
Aetna Medicare Advantage plans may cover prescription drugs, and offer other benefits that Original Medicare doesn’t cover.
Aetna Medicare Signature Extra (PPO) H5521-759 basic costs and coverage
Learn more about the costs, benefits and coverage of Aetna Medicare Signature Extra (PPO) H5521-759 below:
| Coverage | Details |
|---|---|
| Monthly plan premium | $0.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $400.00 |
| Out-of-pocket maximum | $7,150.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,100.00 |
| Primary care provider visit | In-Network $0 Out-of-Network 40% |
| Specialty doctor visit | In-Network $40 Out-of-Network 40% |
| Inpatient hospital care | In-Network $350 per day, days 1-5; $0 per day, days 6-90 Out-of-Network 40% per stay |
| Urgent care | Urgent Care: Copayment for Urgent Care $50 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $130 Maximum Plan Benefit of $250,000 |
| Emergency room visit | $130 If you are admitted to the hospital within 24 hours your cost share may be waived |
| Ambulance transportation | In-Network $310 Out-of-Network $310 |
Additional health services and supplies coverage
Aetna Medicare Signature Extra (PPO) H5521-759 covers additional health services and medical supplies. Learn more below:
| Coverage | Details |
|---|---|
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network 0% for continuous glucose monitors (CGM) at participating providers 0% for Accu-Chek/Roche and TRUE/Trividia blood glucose meters (BGM) and medical diabetic supplies 20% for blood glucose meters (BGM) and supplies manufactured by providers other than Accu-Chek/Roche and TRUE/Trividia with an approved prior authorization Out-of-Network 0% for Accu-Chek/Roche and TRUE/Trividia blood glucose meters (BGM) and medical diabetic supplies 40% for blood glucose meters (BGM) and supplies manufactured by providers other than Accu-Chek/Roche and TRUE/Trividia with an approved prior authorization 40% for continuous glucose monitors (CGM) |
| Durable medical equipment (DME) | In-Network 20% Out-of-Network 40% |
| Diagnostic tests, lab and radiology services, and X-rays | Lab Services: In-Network $0 Out-of-Network 40% Diagnostic Procedures: In-Network $0 for certain Medicare-covered diagnostic tests and services including Retinal fundus, Spirometry, Peripheral arterial disease (PAD) $20 for other diagnostic procedures and tests Out-of-Network 40% Imaging: In-Network Xray: $15 CT Scans: $300 Diagnostic Radiology other than CT Scans: $300 Diagnostic Radiology Mammogram: $0 Out-of-Network 40% |
| Home health care | In-Network $0 Out-of-Network 40% |
| Mental health inpatient care | In-Network: Psychiatric Hospital Services: $400 per day for days 1 to 5 $0 per day for days 6 to 90 Prior Authorization Required for Psychiatric Hospital Services |
| Mental health outpatient care | In-Network $40 for Mental Health - Group Sessions $40 for Mental Health - Individual Sessions $40 for Psychiatric Services - Group Sessions $40 for Psychiatric Services - Individual Sessions Out-of-Network 40% for Mental Health Services- Group Sessions 40% for Mental Health Services - Individual Sessions 40% for Psychiatric Services - Group Sessions 40% for Psychiatric Services - Individual Sessions |
| Outpatient services/surgery | Ambulatory Surgical Center: In-Network $0 for preventive and diagnostic colonoscopy $300 all other ambulatory surgical center services Out-of-Network 40% |
| Outpatient substance abuse care | Out-of-Network: Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual Sessions 40% Coinsurance for Medicare Covered Group Sessions 40% |
| Over-the-counter items | Over-the-Counter (OTC) Wallet with a $25 quarterly benefit amount (allowance) on the Extra Benefits Card to help pay for approved OTC health and wellness products like first aid supplies, cold and allergy medicine, pain relievers, and more. Approved products can be purchased in-store at participating locations including CVS retail locations (excluding locations inside other stores), using the app, online or by phone through CVS Flex Benefits. |
| Podiatry services | Out-of-Network: Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 40% |
| Skilled Nursing Facility (SNF) care | In-Network $0 per day, days 1-20; $221 per day, days 21-100 Out-of-Network 40% per stay |
Dental benefit
Aetna Medicare Signature Extra (PPO) H5521-759 offers the following dental benefit and coverage. There may be provider network restrictions. You can find more information about network restrictions in the plan’s Evidence of Coverage.
| Coverage | Details |
|---|---|
| Dental care | In-Network Preventive dental services: $0 for oral exams $0 for cleanings $0 for x-rays Comprehensive dental services: 20%-50% for restorative services 20% for endodontic services 20%-50% for periodontic services 50% for removeable prosthodontics 50% for fixed prosthodontics 20% - 50% for oral and maxillofacial surgery 20% - 50% for adjunctive services Out-of-Network Preventive dental services: 50% for oral exams 50% for cleanings 50% for x-rays Comprehensive dental services: 50% - 70% for restorative services 50% for endodontic services 50% - 70% for periodontic services 70% for removeable prosthodontics 70% for fixed prosthodontics 50% - 70% for oral and maxillofacial surgery 50% - 70% for adjunctive services $750 benefit amount (allowance) every year in and out-of-network for covered comprehensive dental services. Frequencies and medical necessity requirements vary by covered dental service. Covered preventive dental services do not count towards your annual benefit amount. See EOC for additional details on exclusions and limitations. |
Vision benefit
Aetna Medicare Signature Extra (PPO) H5521-759 offers the following vision benefit. There may be provider network restrictions. You can find more information about network restrictions in the plan's Evidence of Coverage.
| Coverage | Details |
|---|---|
| Vision care | In-Network Eye Exams: $0 for Medicare-covered eye exams $0 for non-Medicare covered routine eye exam with an EyeMed network provider Eyewear: $0 for Medicare-covered prescription eyewear $175 annual benefit amount (allowance) for non-Medicare covered prescription eyewear through an EyeMed network provider. $0 for Contacts $0 for Eyeglasses $0 for Eyeglass Frames $0 for Eyeglass Lenses $0 for Upgrades Out-of-Network Eye Exams: 40% for Medicare-covered eye exams $0 for non-Medicare covered routine eye exam (out of network covered up to $50) Eyewear: 40% for Medicare-covered prescription eyewear $175 annual benefit amount (allowance) for non-Medicare covered prescription eyewear $0 for Contacts $0 for Eyeglass Frames $0 for Eyeglass Lenses $0 for Eyeglass Lenses and Frames $0 for Upgrades Maximum one non-Medicare covered routine eye exam every calendar year in or out-of-network. Maximum one annual benefit amount for non-Medicare covered prescription eyewear in or out-of-network. |
Hearing benefit
Aetna Medicare Signature Extra (PPO) H5521-759 offers the following hearing benefit and coverage. There may be provider network restrictions. You can find more information about network restrictions in the plan’s Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | In-Network Hearing Exams: $0 for Medicare-covered hearing exams $0 for non-Medicare covered hearing exams (Maximum one non-Medicare covered hearing exam every year in or out-of-network) $0 for fitting/evaluation for hearing aids (Maximum one hearing aid fitting/evaluation every year) Hearing Aids: $0 for hearing aids $1,250 benefit amount (allowance) per ear, every year for hearing aids (Maximum two hearing aids every year) Out-of-Network: Hearing Exams: 40% for Medicare-covered hearing exams 40% for non-Medicare covered hearing exam every year in or out-of-network Hearing Aids: You must purchase hearing aids through NationsHearing |
Preventive services and health/wellness education programs
Aetna Medicare Signature Extra (PPO) H5521-759 offers the following preventive services, benefits and wellness programs. There may be provider network restrictions. You can find more information about network restrictions in the plan’s Evidence of Coverage.
| Coverage | Details |
|---|---|
| Preventive services and health/wellness education programs | In-Network $0 for all preventive services covered under Original Medicare Out-of-Network 0% for the pneumonia, influenza, Hepatitis B, and Covid-19 vaccines 40% for all other preventive services covered under Original Medicare |
We can help you find out if your doctors are in a plan’s network when reviewing Aetna Medicare Advantage plans in North Dakota. We can also help you look for plans that cover your prescription drugs.
There may be other Aetna Medicare Advantage plans available in North Dakota. Call 1-800-891-6309 (TTY: 711), 24/7 to speak with a licensed TZ insurance agent* who can help you compare plans where you live.
Plan documents
Learn more about Aetna Medicare Signature Extra (PPO) H5521-759 by reviewing the following documents:
| Links to plan documents |
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