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H5521 - 142 - 0
(4.5 / 5)
Aetna Medicare Explorer Plan (PPO)is a Medicare Advantage (Part C) Plan by Aetna Medicare.
This page features plan details for 2022 Aetna Medicare Explorer Plan (PPO)H5521 – 142 – 0 available in Southern Maine.
IMPORTANT: This page features the 2022 version of this plan. See the 2024 version using the link below:
No 2024 version found. You can use the location links below to find 2024 plans in your area.
Locations
Aetna Medicare Explorer Plan (PPO)is offered in the following locations.
Maine
Sagadahoc County, Maine
Click to see more locations
Plan Overview
Aetna Medicare Explorer Plan (PPO)offers the following coverage and cost-sharing.
Insurer: | Aetna Medicare |
Health Plan Deductible: | $0 |
MOOP: | $7,550.00 |
Drugs Covered: | Yes |
Please Note:
- This plan does not charge an annual deductible for all drugs. The $250.00 annual deductible only applies to drugs on certain tiers.
Ready to sign up for Aetna Medicare Explorer Plan (PPO)?
Premium Breakdown
Aetna Medicare Explorer Plan (PPO)has a monthly premium of $40.5. This amount includes your Part C and D premiums but does not include your Part B premium.The following is a breakdown of your monthly premium with Part B costs included.
Part B | Part C | Part D | Part B Give Back | Total |
---|---|---|---|---|
$170.10 | $8.50 | $40.50 | $0.00 | $219.10 |
Please Note:
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
- You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.
Drug Info
Aetna Medicare Explorer Plan (PPO)provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
Drug Deductible: | $250.00 |
Initial Coverage Limit: | $4,430.00 |
Catastrophic Coverage Limit: | $7,050.00 |
Drug Benefit Type: | Enhanced |
Gap Coverage: | Yes |
Formulary Link: | Formulary Link |
Part D Premium Reduction
The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.The table below shows how the LIS impacts the Part D premium of this plan.
Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
---|---|---|---|---|
$40.50 | $32.90 | $25.20 | $17.60 | $10.00 |
Initial Coverage Phase
After you pay your $250.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,430.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
60 Day
90 Day
Gap Coverage Phase
After your total drug costs (including what this plan has paid and what you have paid) reach $4,430.00, you will pay no more than the amounts below for any drug tier until you reach $7,050.00.
30 Day
90 Day
30 Day
90 Day
Tier | Cost |
---|---|
All other tiers (Generic) | 25% |
All other tiers (Brand-name) | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,050.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
Tier | Cost |
---|---|
Generic | $4.15 copay or 5% (whichever costs more) |
Brand-name | $10.35 copay or 5% (whichever costs more) |
Additional Benefits
Aetna Medicare Explorer Plan (PPO)also provides the following benefits.
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
In-Network: No |
Dental (comprehensive)
Diagnostic services: | In-Network: $0 copay (limits may apply) (authorization required) |
Diagnostic services: | Out-of-Network: $0 copay (limits may apply) (authorization required) |
Endodontics: | In-Network: $0 copay (limits may apply) (authorization required) |
Endodontics: | Out-of-Network: $0 copay (limits may apply) (authorization required) |
Extractions: | In-Network: $0 copay (limits may apply) (authorization required) |
Extractions: | Out-of-Network: $0 copay (limits may apply) (authorization required) |
Non-routine services: | In-Network: $0 copay (limits may apply) (authorization required) |
Non-routine services: | Out-of-Network: $0 copay (limits may apply) (authorization required) |
Periodontics: | In-Network: $0 copay (limits may apply) (authorization required) |
Periodontics: | Out-of-Network: $0 copay (limits may apply) (authorization required) |
Prosthodontics, other oral/maxillofacial surgery, other services: | In-Network: $0 copay (limits may apply) (authorization required) |
Prosthodontics, other oral/maxillofacial surgery, other services: | Out-of-Network: $0 copay (limits may apply) (authorization required) |
Restorative services: | In-Network: $0 copay (limits may apply) (authorization required) |
Restorative services: | Out-of-Network: $0 copay (limits may apply) (authorization required) |
Dental (preventive)
Cleaning: | In-Network: $0 copay (limits may apply) |
Cleaning: | Out-of-Network: $0 copay (limits may apply) |
Dental x-ray(s): | In-Network: $0 copay (limits may apply) |
Dental x-ray(s): | Out-of-Network: $0 copay (limits may apply) |
Fluoride treatment: | In-Network: $0 copay (limits may apply) |
Fluoride treatment: | Out-of-Network: $0 copay (limits may apply) |
Oral exam: | In-Network: $0 copay (limits may apply) |
Oral exam: | Out-of-Network: $0 copay (limits may apply) |
Diagnostic procedures/lab services/imaging
Diagnostic radiology services (e.g., MRI): | In-Network: $0-150 copay (authorization required) |
Diagnostic radiology services (e.g., MRI): | Out-of-Network: 40% coinsurance (authorization required) |
Diagnostic tests and procedures: | In-Network: $0-40 copay (authorization required) |
Diagnostic tests and procedures: | Out-of-Network: 40% coinsurance (authorization required) |
Lab services: | In-Network: $0 copay (authorization required) |
Lab services: | Out-of-Network: 40% coinsurance (authorization required) |
Outpatient x-rays: | In-Network: $0-25 copay (authorization required) |
Outpatient x-rays: | Out-of-Network: 40% coinsurance (authorization required) |
Doctor visits
Primary: | In-Network: $0 copay |
Primary: | Out-of-Network: 40% coinsurance per visit |
Specialist: | In-Network: $40 copay per visit |
Specialist: | Out-of-Network: 40% coinsurance per visit |
Emergency care/Urgent care
Emergency: | $90 copay per visit (always covered) |
Urgent care: | $0-40 copay per visit (always covered) |
Foot care (podiatry services)
Foot exams and treatment: | In-Network: $40 copay |
Foot exams and treatment: | Out-of-Network: 40% coinsurance |
Routine foot care: | Not covered |
Ground ambulance
In-Network: $295 copay | |
Out-of-Network: $295 copay |
Health plan deductible
$0.00 |
Health plan deductibles (other)
In-Network: No |
Hearing
Fitting/evaluation: | In-Network: $0 copay (limits may apply) |
Fitting/evaluation: | Out-of-Network: 40% coinsurance (limits may apply) |
Hearing aids: | In-Network: $0-1,700 copay (limits may apply) |
Hearing aids: | Out-of-Network: $0-1,700 copay (limits may apply) |
Hearing exam: | In-Network: $40 copay |
Hearing exam: | Out-of-Network: 40% coinsurance |
Hospital coverage (inpatient)
In-Network: $310 per day for days 1 through 7 $0 per day for days 8 through 90 (authorization required) | |
Out-of-Network: 40% per stay (authorization required) |
Hospital coverage (outpatient)
In-Network: $0-295 copay per visit (authorization required) | |
Out-of-Network: 40% coinsurance per visit (authorization required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
$7,550 In and Out-of-network $7,550 In-network |
Medical equipment/supplies
Diabetes supplies: | In-Network: 0-20% coinsurance per item (authorization required) |
Diabetes supplies: | Out-of-Network: 0-20% coinsurance per item (authorization required) |
Durable medical equipment (e.g., wheelchairs, oxygen): | In-Network: 20% coinsurance per item (authorization required) |
Durable medical equipment (e.g., wheelchairs, oxygen): | Out-of-Network: 40% coinsurance per item (authorization required) |
Prosthetics (e.g., braces, artificial limbs): | In-Network: 20% coinsurance per item (authorization required) |
Prosthetics (e.g., braces, artificial limbs): | Out-of-Network: 40% coinsurance per item (authorization required) |
Medicare Part B drugs
Chemotherapy: | In-Network: 20% coinsurance (authorization required) |
Chemotherapy: | Out-of-Network: 40% coinsurance (authorization required) |
Other Part B drugs: | In-Network: 20% coinsurance (authorization required) |
Other Part B drugs: | Out-of-Network: 40% coinsurance (authorization required) |
Mental health services
Inpatient hospital – psychiatric: | In-Network: $1,871 per stay (authorization required) |
Inpatient hospital – psychiatric: | Out-of-Network: 40% per stay (authorization required) |
Outpatient group therapy visit with a psychiatrist: | In-Network: $40 copay (authorization required) |
Outpatient group therapy visit with a psychiatrist: | Out-of-Network: 40% coinsurance (authorization required) |
Outpatient group therapy visit: | In-Network: $40 copay (authorization required) |
Outpatient group therapy visit: | Out-of-Network: 40% coinsurance (authorization required) |
Outpatient individual therapy visit with a psychiatrist: | In-Network: $40 copay (authorization required) |
Outpatient individual therapy visit with a psychiatrist: | Out-of-Network: 40% coinsurance (authorization required) |
Outpatient individual therapy visit: | In-Network: $40 copay (authorization required) |
Outpatient individual therapy visit: | Out-of-Network: 40% coinsurance (authorization required) |
Optional supplemental benefits
No |
Preventive care
In-Network: $0 copay | |
Out-of-Network: 0-40% coinsurance |
Rehabilitation services
Occupational therapy visit: | In-Network: $40 copay (authorization required) |
Occupational therapy visit: | Out-of-Network: 40% coinsurance (authorization required) |
Physical therapy and speech and language therapy visit: | In-Network: $40 copay (authorization required) |
Physical therapy and speech and language therapy visit: | Out-of-Network: 40% coinsurance (authorization required) |
Skilled Nursing Facility
In-Network: $0 per day for days 1 through 20 $188 per day for days 21 through 62 $0 per day for days 63 through 100 (authorization required) | |
Out-of-Network: 40% per stay (authorization required) |
Transportation
Not covered |
Vision
Contact lenses: | In-Network: $0 copay (limits may apply) |
Contact lenses: | Out-of-Network: $0 copay (limits may apply) |
Eyeglass frames: | In-Network: $0 copay (limits may apply) |
Eyeglass frames: | Out-of-Network: $0 copay (limits may apply) |
Eyeglass lenses: | In-Network: $0 copay (limits may apply) |
Eyeglass lenses: | Out-of-Network: $0 copay (limits may apply) |
Eyeglasses (frames and lenses): | In-Network: $0 copay (limits may apply) |
Eyeglasses (frames and lenses): | Out-of-Network: $0 copay (limits may apply) |
Other: | In-Network: $0 copay |
Other: | Out-of-Network: 40% coinsurance |
Routine eye exam: | In-Network: $0 copay (limits may apply) |
Routine eye exam: | Out-of-Network: 40% coinsurance (limits may apply) |
Upgrades: | In-Network: $0 copay (limits may apply) |
Upgrades: | Out-of-Network: $0 copay (limits may apply) |
Wellness programs (e.g., fitness, nursing hotline)
Covered |
Ready to sign up for Aetna Medicare Explorer Plan (PPO)?
Table of Contents
Get Help Enrolling
Get help enrolling in a Medicare Advantage or Medicare Prescription Drug Plan by calling a licensed insurance agent today.
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
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