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Aetna Medicare Signature Giveback (PPO) - H5521-140-000
$0.00
Monthly Premium
Aetna Medicare Signature Giveback (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna®
Plan ID: H5521-140-000
** 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 South Carolina, 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 plans may offer other benefits that Original Medicare doesn’t cover.
Enrollment may be limited to certain times of the year. See why you may be able to enroll.
Aetna Medicare Signature Giveback (PPO) Basic Costs and Coverage
Learn more about the costs, benefits and coverage of Aetna Medicare Signature Giveback (PPO) below:
| Coverage | Details |
|---|---|
| Monthly plan premium | $0.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $500.00 |
| Out-of-pocket maximum | $8,200.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,100.00 |
| Primary care doctor visit | Out-of-Network|$10 |
| Specialty doctor visit | In-Network|$0 for services provided in a nursing home|$45 for services provided outside a nursing home |
| Inpatient hospital care | In-Network|$388 per day, days 1-7; $0 per day, days 8-90||Out-of-Network|$488 per day, days 1-7; $0 per day, days 8-90 |
| Urgent care | Urgent Care: Copayment for Urgent Care $40 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $115 Maximum Plan Benefit of $250,000 |
| Emergency room visit | $115 If you are admitted to the hospital within 24 hours your cost share may be waived |
| Ambulance transportation | In-Network|$275 |
Additional Health Services and Supplies Coverage
Aetna Medicare Signature Giveback (PPO) may cover additional health services and medical supplies. Learn more below:
| Coverage | Details |
|---|---|
| Chiropractic services | Out-of-Network: Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 20% |
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network|0% for Roche/Accu-Chek and TRUE/Trividia diabetic supplies|20% for other covered diabetic supplies |
| Durable medical equipment (DME) | Out-of-Network|20% |
| Diagnostic tests, lab and radiology services, and X-rays | Lab Services: Out-of-Network|20% Diagnostic Procedures: Out-of-Network|20% Imaging: Out-of-Network|20% |
| Home health care | Out-of-Network|20% |
| Mental health inpatient care | Out-of-Network: Psychiatric Hospital Services: Coinsurance for Psychiatric Hospital per Stay 20% |
| Mental health outpatient care | Out-of-Network|20% for Mental Health Services- Group Sessions|20% for Mental Health Services - Individual Sessions|20% for Psychiatric Services - Group Sessions|20% for Psychiatric Services - Individual Sessions |
| Outpatient services/surgery | Ambulatory Surgical Center: Out-of-Network|$438 |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $40 Copayment for Medicare-covered Group Sessions $40 Prior Authorization Required for Outpatient Substance Abuse Services |
| Over-the-counter items | CVS Over-the-Counter (OTC) Wallet with a $30 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 CVS retail locations (excluding locations inside other stores), and online or by phone through CVS OTC Health Solutions. |
| Podiatry services | Out-of-Network: Podiatry Services: Copayment for Medicare Covered Podiatry Services $55 |
| Skilled Nursing Facility (SNF) care | Out-of-Network|20% per stay |
Dental Benefits
Aetna Medicare Signature Giveback (PPO) offers the following dental benefits 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 | 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||$1,000 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 Benefits
Aetna Medicare Signature Giveback (PPO) offers the following vision benefits. There may be provider network restrictions. You can find more information about network restrictions in the Evidence of Coverage.
| Coverage | Details |
|---|---|
| Vision care | In-Network||Eye Exams:|$0 for Diabetic eye exams|$45 for all other Medicare-covered eye exams|$0 for non-Medicare covered eye exams|Maximum one non-Medicare covered routine eye exam every calendar year in or out-of-network with an EyeMed provider||Eyewear:|$0 for Medicare-covered prescription eyewear|$0 for Contacts|$0 for Eyeglasses|$0 for Eyeglass Frames|$0 for Eyeglass Lenses|$0 for Upgrades |
Hearing Benefits
Aetna Medicare Signature Giveback (PPO) offers the following hearing benefits 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:|$45 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) |
Preventive Services and Health/Wellness Education Programs
Aetna Medicare Signature Giveback (PPO) 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 | Out-of-Network|$0 for all preventive services covered under Original Medicare |
Prescription Drug Costs and Coverage
Aetna Medicare Signature Giveback (PPO) offers prescription drug coverage, with an annual drug deductible of $500.00 (excludes Tiers 1 and 2)
Coverage & Cost | |
|---|---|
| Coverage | Cost |
| Annual drug deductible | $500.00 (excludes Tiers 1 and 2) |
| Tier 1 - Preferred Generic |
|
| Tier 2 - Generic |
|
| Annual drug deductible | $500.00 (excludes Tiers 1 and 2) |
| Tier 1 - Preferred Generic |
|
| Tier 2 - Generic |
|
| Annual drug deductible | $500.00 (excludes Tiers 1 and 2) |
| Tier 1 - Preferred Generic |
|
| Tier 2 - Generic |
|
We can help you find out if your doctors are in a plan’s network when reviewing Aetna Medicare Advantage plans in South Carolina. We can also help you look for plans that cover your prescription drugs.
There may be other Aetna Medicare Advantage plans available in South Carolina. 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 Giveback (PPO) by reviewing the following documents:
| Links to plan documents |