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2022 Plan Guide
NYC-QUEENS
Below are in-network costs for some of our Medicare benefits. It's not a complete list. For more information about these plans, refer to the Summary of Benefits, visit our website AetnaMedicare.com or call us at 1-833-859-6031
(TTY: 711).
Benefits listed are for Aetna Medicare Aetna Medicare Aetna Medicare Discover Aetna Medicare Aetna Medicare Aetna Medicare
services received in- Elite Plan (PPO) Elite Plan 3 (PPO) Value Plan (PPO) Elite Plan (HMO) Premier Plan (PPO) Eagle Plan (PPO)
network and per visit unless H5521-120 H5521-310 H5521-312 H3312-068 H5521-040 H5521-320
otherwise stated Monthly Plan Premium: $0 Monthly Plan Premium: $25 Monthly Plan Premium: $26 Monthly Plan Premium: $39 Monthly Plan Premium: $99 Monthly Plan Premium: $0
Service area NY-Bronx, Kings, Nassau, NY-Kings, New York, NY-Kings, New York, Queens NY-New York, Queens NY-Kings, Nassau, New NY-Bronx, Kings, Nassau,
New York, Queens, Queens, Richmond York, Queens, Richmond New York, Queens,
Richmond, Rockland, Richmond, Rockland,
Suffolk, Westchester Suffolk, Westchester
Plan deductible $1,000* for certain in- $1,000* for certain in- $0 $500* for certain in- $0 $0
network and out-of- network and out-of- network services.
network services combined. network services combined.
Annual maximum out- $7,550 for in- $7,550 for in- $7,550 for in- $7,550 $5,000 for in- $7,550 for in-
of-pocket amount (does network services. network services. network services. network services. network services.
not include premium or $11,300 for in- and out-of- $11,300 for in- and out-of- $11,300 for in- and out-of- $6,000 for in- and out-of- $11,300 for in- and out-of-
prescription drugs) network services combined. network services combined. network services combined. network services combined. network services combined.
* Deductible will apply to the following in-network services: Inpatient hospital, inpatient psychiatric, skilled nursing facility, therapeutic radiology, outpatient hospital services (including observation), ambulatory surgery center (ASC) and
dialysis. See the Evidence of Coverage for details.
Hospital coverage
Inpatient hospital coverage $850 per stay after $795 per stay after $395 per day, days 1-5; $850 per stay after $335 per day, days 1-6; $395 per day, days 1-5;
plan deductible plan deductible $0 per day, days 6-90 plan deductible $0 per day, days 7-90 $0 per day, days 6-90
Plan covers unlimited Plan covers unlimited $0 copay for additional days. Plan covers unlimited $0 copay for additional days. $0 copay for additional days.
hospital days. hospital days. Plan covers unlimited hospital days. Plan covers unlimited Plan covers unlimited
hospital days. hospital days. hospital days.
Outpatient hospital $45 - $395 after $35 - $350 after $40 - $395 $45 - $395 after $45 - $395 $40 - $500
plan deductible plan deductible Lower cost sharing is plan deductible Lower cost sharing is Lower cost sharing is
Lower cost sharing is Lower cost sharing is for outpatient hospital Lower cost sharing is for outpatient hospital for outpatient hospital
for outpatient hospital for outpatient hospital services other than surgery. for outpatient hospital services other than surgery. services other than surgery.
services other than surgery. services other than surgery. services other than surgery.
Ambulatory surgery center $250 after plan deductible $200 after plan deductible $200 $250 after plan deductible $200 $250
(ASC)
Skilled nursing facility $0 per day, days 1-20; $0 per day, days 1-20; $0 per day, days 1-20; $0 per day, days 1-20; $0 per day, days 1-20; $0 per day, days 1-20;
$188 per day, days 21-100 $188 per day, days 21-100 $188 per day, days 21-100 $188 per day, days 21-100 $188 per day, days 21-100 $188 per day, days 21-100
after plan deductible after plan deductible Our plan covers up to 100 after plan deductible Our plan covers up to 100 Our plan covers up to 100
Our plan covers up to 100 Our plan covers up to 100 days per benefit period. Our plan covers up to 100 days per benefit period. days per benefit period.
days per benefit period. days per benefit period. days per benefit period.
1 PG22-NY04-NYC-QUEENS
Benefits listed are for Aetna Medicare Aetna Medicare Aetna Medicare Discover Aetna Medicare Aetna Medicare Aetna Medicare
services received in- Elite Plan (PPO) Elite Plan 3 (PPO) Value Plan (PPO) Elite Plan (HMO) Premier Plan (PPO) Eagle Plan (PPO)
network and per visit unless H5521-120 H5521-310 H5521-312 H3312-068 H5521-040 H5521-320
otherwise stated Monthly Plan Premium: $0 Monthly Plan Premium: $25 Monthly Plan Premium: $26 Monthly Plan Premium: $39 Monthly Plan Premium: $99 Monthly Plan Premium: $0
Doctor visits
Primary care physician (PCP) $5 $0 $0 $10 $5 $0
PCP referrals required This plan doesn't require a This plan doesn't require a This plan doesn't require a This plan doesn't require a This plan doesn't require a This plan doesn't require a
referral to see a specialist, referral to see a specialist, referral to see a specialist, referral to see a specialist, referral to see a specialist, referral to see a specialist,
but the specialist may but the specialist may but the specialist may but the specialist may but the specialist may but the specialist may
require one from your PCP. require one from your PCP. require one from your PCP. require one from your PCP. require one from your PCP. require one from your PCP.
Specialist $45 $35 $40 $45 $45 $40
Outpatient mental health $40 $40 $40 $40 $40 $40
therapy (individual)
Emergency and urgent care
Emergency room $90 $90 $90 $90 $90 $90
Urgent care facility $65 $65 $65 $65 $65 $65
Worldwide coverage (i.e., $90 for emergency and $90 for emergency and $90 for emergency and $90 for emergency and $90 for emergency and $90 for emergency and
outside of the United States) urgent care worldwide. urgent care worldwide. urgent care worldwide. urgent care worldwide. urgent care worldwide. urgent care worldwide.
Diagnostic testing
X-rays and diagnostic X-rays: $50 X-rays: $50 X-rays: $50 X-rays: $50 X-rays: $50 X-rays: $50
radiology
Diagnostic radiology: $375 Diagnostic radiology: $295 Diagnostic radiology: $350 Diagnostic radiology: $325 Diagnostic radiology: $325 Diagnostic radiology: $375
Lab services $0 $5 $0 $0 $0 $0
You'll pay $0 for
certain lab services.
Dental, vision and hearing (Non-Medicare covered)
Dental services See optional supplemental $1,000 maximum benefit $1,000 maximum benefit $0 for preventive services. $0 for preventive services. $1,000 maximum benefit
benefits below. in- and out-of-network in- and out-of-network Comprehensive services Comprehensive services in- and out-of-network
every year for preventive every year for preventive are covered under optional are covered under optional every year for preventive
and comprehensive and comprehensive supplemental benefits. supplemental benefits. and comprehensive
dental combined. dental combined. dental combined.
Aetna Dental® PPO Network Aetna Dental® PPO Network
Aetna Dental® PPO Network Aetna Dental® PPO Network Aetna Dental® PPO Network
Routine eye exam $0 (one exam every year) $0 (one exam every year) $0 (one exam every year) $0 (one exam every year) $0 (one exam every year) $0 (one exam every year)
2 PG22-NY04-NYC-QUEENS
Benefits listed are for Aetna Medicare Aetna Medicare Aetna Medicare Discover Aetna Medicare Aetna Medicare Aetna Medicare
services received in- Elite Plan (PPO) Elite Plan 3 (PPO) Value Plan (PPO) Elite Plan (HMO) Premier Plan (PPO) Eagle Plan (PPO)
network and per visit unless H5521-120 H5521-310 H5521-312 H3312-068 H5521-040 H5521-320
otherwise stated Monthly Plan Premium: $0 Monthly Plan Premium: $25 Monthly Plan Premium: $26 Monthly Plan Premium: $39 Monthly Plan Premium: $99 Monthly Plan Premium: $0
Eyewear See optional supplemental $100 reimbursement** $150 reimbursement** $100 reimbursement** $175 reimbursement** $200 reimbursement**
benefits below. every year. every year. every year. every year. every year.
You can see any licensed You can see any licensed You can see any licensed You can see any licensed You can see any licensed
provider. Discounts may provider. Discounts may provider. Discounts may provider. Discounts may provider. Discounts may
be available when seeing be available when seeing be available when seeing be available when seeing be available when seeing
an EyeMed provider. an EyeMed provider. an EyeMed provider. an EyeMed provider. an EyeMed provider.
Routine hearing exam $0 (one exam every year) $0 (one exam every year) $0 (one exam every year) $0 (one exam every year) $0 (one exam every year) $0 (one exam every year)
All appointments All appointments All appointments All appointments All appointments All appointments
should be scheduled should be scheduled should be scheduled must be scheduled should be scheduled should be scheduled
through NationsHearing. through NationsHearing. through NationsHearing. through NationsHearing. through NationsHearing. through NationsHearing.
Hearing aids $750 (per ear) maximum $1,250 (per ear) maximum $1,250 (per ear) maximum $1,250 (per ear) maximum $1,250 (per ear) maximum $1,250 (per ear) maximum
benefit every year. benefit every year. benefit every year. benefit every year. benefit every year. benefit every year.
All hearing aids should All hearing aids should All hearing aids should All hearing aids must All hearing aids should All hearing aids should
be purchased through be purchased through be purchased through be purchased through be purchased through be purchased through
NationsHearing. NationsHearing. NationsHearing. NationsHearing. NationsHearing. NationsHearing.
**Member pays the provider upfront and we pay the member back. Plan coverage rules apply.
Therapy
Physical and speech therapy $40 $40 $40 $40 $40 $40
Occupational therapy $40 $40 $40 $40 $40 $40
Ambulance
Ground ambulance (one-way $270 $255 $235 $250 $265 $250
trip)
Air ambulance (one-way trip) $270 $255 $235 $250 $265 $250
Equipment and prosthetics
Durable medical equipment 20% 20% 20% 20% 20% 20%
Prosthetics 20% 20% 20% 20% 20% 20%
3 PG22-NY04-NYC-QUEENS
Additional benefits Aetna Medicare Aetna Medicare Aetna Medicare Discover Aetna Medicare Aetna Medicare Aetna Medicare
Elite Plan (PPO) Elite Plan 3 (PPO) Value Plan (PPO) Elite Plan (HMO) Premier Plan (PPO) Eagle Plan (PPO)
H5521-120 H5521-310 H5521-312 H3312-068 H5521-040 H5521-320
Monthly Plan Premium: $0 Monthly Plan Premium: $25 Monthly Plan Premium: $26 Monthly Plan Premium: $39 Monthly Plan Premium: $99 Monthly Plan Premium: $0
24-Hour Nurse Line $0 $0 $0 $0 $0 $0
Speak with a registered Speak with a registered Speak with a registered Speak with a registered Speak with a registered Speak with a registered
nurse 24 hours a day, 7 days nurse 24 hours a day, 7 days nurse 24 hours a day, 7 days nurse 24 hours a day, 7 days nurse 24 hours a day, 7 days nurse 24 hours a day, 7 days
a week to discuss medical a week to discuss medical a week to discuss medical a week to discuss medical a week to discuss medical a week to discuss medical
issues or wellness topics. issues or wellness topics. issues or wellness topics. issues or wellness topics. issues or wellness topics. issues or wellness topics.
Acupuncture services Not covered $35 (up to twelve visits $40 (up to twelve visits $45 (up to twelve visits Not covered Not covered
(additional) every year through Aetna) every year through Aetna) every year through Aetna)
Fitness SilverSneakers® SilverSneakers® SilverSneakers® SilverSneakers® SilverSneakers® SilverSneakers®
Meals Up to 14 home delivered meals Up to 14 home delivered meals Up to 14 home delivered meals Up to 14 home delivered meals Up to 14 home delivered meals Up to 14 home delivered meals
over a 7-day period after being over a 7-day period after being over a 7-day period after being over a 7-day period after being over a 7-day period after being over a 7-day period after being
discharged from an Inpatient discharged from an Inpatient discharged from an Inpatient discharged from an Inpatient discharged from an Inpatient discharged from an Inpatient
Acute Hospital, Inpatient Acute Hospital, Inpatient Acute Hospital, Inpatient Acute Hospital, Inpatient Acute Hospital, Inpatient Acute Hospital, Inpatient
Psychiatric Hospital or Skilled Psychiatric Hospital or Skilled Psychiatric Hospital or Skilled Psychiatric Hospital or Skilled Psychiatric Hospital or Skilled Psychiatric Hospital or Skilled
Nursing Facility to home. Nursing Facility to home. Nursing Facility to home. Nursing Facility to home. Nursing Facility to home. Nursing Facility to home.
Over-the-counter items (OTC) Not covered Not covered $45 maximum benefit You'll be mailed a one-time Not covered $60 maximum benefit
every quarter through box of preselected OTC items. every quarter through
OTC Health Solutions or at OTC Health Solutions or at
participating CVS® stores. participating CVS® stores.
You'll also be mailed
a one-time box of
preselected OTC items.
Telehealth You can receive primary You can receive primary You can receive primary You can receive primary You can receive primary You can receive primary
care, physician specialist, care, physician specialist, care, physician specialist, care, physician specialist, care, physician specialist, care, physician specialist,
mental health and urgent care mental health and urgent care mental health and urgent care mental health and urgent care mental health and urgent care mental health and urgent care
services through a virtual visit. services through a virtual visit. services through a virtual visit. services through a virtual visit. services through a virtual visit. services through a virtual visit.
Members should contact Members should contact Members should contact Members should contact Members should contact Members should contact
their doctor for information on their doctor for information on their doctor for information on their doctor for information on their doctor for information on their doctor for information on
what telehealth services they what telehealth services they what telehealth services they what telehealth services they what telehealth services they what telehealth services they
offer and how to schedule a offer and how to schedule a offer and how to schedule a offer and how to schedule a offer and how to schedule a offer and how to schedule a
telehealth visit. Depending on telehealth visit. Depending on telehealth visit. Depending on telehealth visit. Depending on telehealth visit. Depending on telehealth visit. Depending on
location, members may also location, members may also location, members may also location, members may also location, members may also location, members may also
have the option to schedule have the option to schedule have the option to schedule have the option to schedule have the option to schedule have the option to schedule
a telehealth visit 24 hours a telehealth visit 24 hours a telehealth visit 24 hours a telehealth visit 24 hours a telehealth visit 24 hours a telehealth visit 24 hours
a day, 7 days a week via a day, 7 days a week via a day, 7 days a week via a day, 7 days a week via a day, 7 days a week via a day, 7 days a week via
Teladoc, MinuteClinic Video Teladoc, MinuteClinic Video Teladoc, MinuteClinic Video Teladoc, MinuteClinic Video Teladoc, MinuteClinic Video Teladoc, MinuteClinic Video
Visit, or other provider that Visit, or other provider that Visit, or other provider that Visit, or other provider that Visit, or other provider that Visit, or other provider that
offers telehealth services offers telehealth services offers telehealth services offers telehealth services offers telehealth services offers telehealth services
covered under your plan. covered under your plan. covered under your plan. covered under your plan. covered under your plan. covered under your plan.
4 PG22-NY04-NYC-QUEENS
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