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Aetna Medicare Signature Giveback (PPO) - H5521-348-000
$0.00
Monthly Premium
Aetna Medicare Signature Giveback (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna®
Plan ID: H5521-348-000
** 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 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 | $615.00 |
| Out-of-pocket maximum | $7,500.00 |
| 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 $50 for services provided outside a nursing home Out-of-Network $60 |
| 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 | Out-of-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 | In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $15 |
| Diabetes supplies, training, nutrition therapy and monitoring | Out-of-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: In-Network $0 for Hemoglobin A1C tests $0 for services provided by your primary care provider in their office $35 for services performed by a provider other than your primary care provider Out-of-Network 20% Diagnostic Procedures: In-Network $0 for certain Medicare-covered diagnostic tests and services including Retinal fundus, Spirometry, Peripheral arterial disease (PAD) $0 for services provided by your primary care provider in their office $200 for services performed by a provider other than your primary care provider Out-of-Network 20% Imaging: In-Network Xray: $0 for services provided by your primary care provider in their office; $14 for services performed by a provider other than your primary care provider CT Scans: $0 for services provided by your primary care provider in their office; $300 for services performed by a provider other than your primary care provider Diagnostic Radiology other than CT Scans: $0 for services provided by your primary care provider in their office; $300 for services performed by a provider other than your primary care provider Diagnostic Radiology Mammogram: $0 Out-of-Network 20% |
| Home health care | Out-of-Network|20% |
| Mental health inpatient care | In-Network: Psychiatric Hospital Services: $260 per day for days 1 to 8 $0 per day for days 9 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 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 $60 |
| 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 | 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 $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 | Out-of-Network||Eye Exams:|$60 for 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 (out of network covered up to $50)||Eyewear:|20% for Medicare-covered prescription eyewear|$0 for Contacts|$0 for Eyeglass Frames|$0 for Eyeglass Lenses|$0 for Eyeglass Lenses and Frames|$0 for Upgrades||$100 annual benefit amount (allowance) for non-Medicare covered prescription eyewear. |
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 | Out-of-Network:||Hearing Exams:|$60 for Medicare-covered hearing exams|$60 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 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 $615.00 (excludes Tiers 1 and 2)
|
Coverage & Cost |
|
|---|---|
Coverage |
Cost |
Annual drug deductible |
$615.00 (excludes Tiers 1 and 2) |
Tier 1 - Preferred Generic |
|
Tier 2 - Generic |
|
Annual drug deductible |
$615.00 (excludes Tiers 1 and 2) |
Tier 1 - Preferred Generic |
|
Tier 2 - Generic |
|
Annual drug deductible |
$615.00 (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 North Carolina. We can also help you look for plans that cover your prescription drugs.
There may be other Aetna Medicare Advantage plans available in North 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 |
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