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2021 Plan Guide
Cleveland, Akron-Canton, Youngstown, OH
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 www.aetnamedicare.com or call us at
1-833-859-6031 (TTY: 711).
Benefits listed are for NEW
services received in-network Aetna Medicare Premier Aetna Medicare Advantra Aetna Medicare Value Plan Aetna Medicare Eagle (HMO) Aetna Medicare Premier 2 Aetna Medicare Premier 1
and per visit unless (HMO) Silver (PPO) (PPO) H0628-015 (PPO) (PPO)
otherwise stated H0628-005 H1608-029 H5521-088 Monthly Plan Premium: $0 H5521-020 H5521-134
Monthly Plan Premium: $0 Monthly Plan Premium: $0 Monthly Plan Premium: $0 Monthly Plan Premium: $124 Monthly Plan Premium: $140
Service area OH-Ashland, Belmont, Carroll, OH-Belmont, Columbiana, OH-Allen, Ashland, Auglaize, OH-Cuyahoga, Franklin, OH-Ashland, Brown, Butler, OH-Ashland, Belmont, Brown,
Columbiana, Cuyahoga, Cuyahoga, Geauga, Harrison, Belmont, Carroll, Columbiana, Summit Clark, Clermont, Columbiana, Butler, Clark, Clermont,
Geauga, Harrison, Jefferson, Jefferson, Lake, Lorain, Crawford, Cuyahoga, Cuyahoga, Delaware, Fairfield, Columbiana, Cuyahoga,
Lake, Lorain, Mahoning, Mahoning, Medina, Trumbull Defiance, Erie, Fulton, Geauga, Franklin, Geauga, Hamilton, Delaware, Fairfield, Franklin,
Medina, Portage, Richland, Hancock, Hardin, Harrison, Hancock, Lake, Licking, Lucas, Geauga, Hamilton, Hancock,
Stark, Summit, Trumbull, Henry, Huron, Jefferson, Lake, Mahoning, Marion, Medina, Harrison, Jefferson, Lake,
Tuscarawas, Wayne Lorain, Lucas, Mahoning, Miami, Muskingum, Portage, Lucas, Mahoning, Marion,
Medina, Mercer, Ottawa, Seneca, Stark, Summit, Medina, Muskingum, Portage,
Paulding, Portage, Putnam, Trumbull, Wood Seneca, Stark, Summit,
Richland, Sandusky, Seneca, Trumbull, Wood
Stark, Summit, Trumbull,
Tuscarawas, Van Wert,
Wayne, Williams, Wood,
Wyandot
Plan deductible $0 $700 for certain $750 for certain $0 $1,500 for certain $1,000 for certain
out-of-network services. out-of-network services. out-of-network services. out-of-network services.
Annual maximum $5,900 $5,900 for in-network $5,900 for in-network $7,550 $4,800 for in-network $6,100 for in-network services.
out-of-pocket amount (does services. services. services. $11,300 for in and
not include premium or $11,300 for in and $11,300 for in and $11,300 for in and out-of-network services
prescription drugs) out-of-network services out-of-network services out-of-network services combined.
combined. combined. combined.
Hospital coverage
Inpatient hospital coverage $350 per day, days 1-5; $0 per $350 per day, days 1-5; $0 per $385 per day, days 1-5; $0 per $250 per day, days 1-8; $0 per $285 per day, days 1-6; $0 per $220 per day, days 1-6; $0 per
day, days 6-90 day, days 6-90 day, days 6-90 day, days 9-90 day, days 7-90 day, days 7-90
$0 copay for additional days. $0 copay for additional days. $0 copay for additional days. $0 copay for additional days. $0 copay for additional days. $0 copay for additional days.
Plan covers unlimited hospital Plan covers unlimited hospital Plan covers unlimited hospital Plan covers unlimited hospital Plan covers unlimited hospital Plan covers unlimited hospital
days. days. days. days. days. days.
Outpatient surgery $30 - $270 $100 - $295 $40 - $325 20% $40 - $170 $30 - $130
1
Allowance – member pays the provider and we pay the member back. Plan coverage rules apply.
1 PG21-OH01-CLEVELAND-AKRON-CANTON-YOUNGSTOWN-OH
Benefits listed are for NEW
services received in-network Aetna Medicare Premier Aetna Medicare Advantra Aetna Medicare Value Plan Aetna Medicare Eagle (HMO) Aetna Medicare Premier 2 Aetna Medicare Premier 1
and per visit unless (HMO) Silver (PPO) (PPO) H0628-015 (PPO) (PPO)
otherwise stated H0628-005 H1608-029 H5521-088 Monthly Plan Premium: $0 H5521-020 H5521-134
Monthly Plan Premium: $0 Monthly Plan Premium: $0 Monthly Plan Premium: $0 Monthly Plan Premium: $124 Monthly Plan Premium: $140
Ambulatory surgery center $245 $245 $325 20% $170 $130
(ASC)
Doctor visits
Primary care physician (PCP) $5 $5 $5 $0 $5 $10
PCP referrals required No No No No No No
Specialist $40 $40 $40 $45 $40 $30
Emergency & urgent care
Emergency room $90 $90 $90 $90 $90 $90
Urgent care facility $5 - $45 $5 - $45 $5 - $45 $0 - $45 $5 - $50 $10 - $45
Worldwide coverage (i.e. $90 for emergency and urgent $90 for emergency and urgent $90 for emergency and urgent $90 for emergency and urgent $90 for emergency and urgent $90 for emergency and urgent
outside of the United States) care worldwide. care worldwide. care worldwide. care worldwide. care worldwide. care worldwide.
Diagnostic testing
X-rays and diagnostic X-rays: $10 - $100 X-rays: $5 - $90 X-rays: $5 - $110 X-rays: $10 - $90 X-rays: $5 - $50 X-rays: $20
radiology Diagnostic radiology: $45 - Diagnostic radiology: $45 - Diagnostic radiology: $235 Diagnostic radiology: 20% Diagnostic radiology: $150 Diagnostic radiology: $140
$235 $235
up to a maximum copay of
$250.
Lab services $0 - $10 $0 - $15 $0 - $15 0% $0 - $10 $0
Dental, vision and hearing
Dental services $0-50% up to $1,000 for $0-50% up to $1,000 for $0-50% up to $1,000 for $0-50% up to $2,000 for $0-50% up to $2,000 for $0 for preventive services.
preventive and comprehensive preventive and comprehensive preventive and comprehensive preventive and comprehensive preventive and comprehensive Comprehensive services are
dental services combined. dental services combined. dental services combined. dental services combined. dental services combined. not covered.
Aetna Medicare Dental Aetna Medicare Dental Aetna Medicare Dental Aetna Medicare Dental Aetna Medicare Dental Aetna Medicare Dental
Network Network Network Network Network Network
Routine eye exam $0 $0 $0 $0 $0 $0
(Non-Medicare covered) (one exam every year) (one exam every year) (one exam every year) (one exam every year) (one exam every year) (one exam every year)
1 1 1
Eyewear $230 maximum benefit every $140 maximum benefit every $160 allowance every year. $265 maximum benefit every $160 allowance every year. $200 allowance every year.
year. year. year.
EyeMed network EyeMed network EyeMed network
Routine hearing exam $0 $0 $0 $0 $0 $0
(Non-Medicare covered) (one exam every year) (one exam every year) (one exam every year) (one exam every year) (one exam every year) (one exam every year)
All appointments must be All appointments should be All appointments should be All appointments must be All appointments should be All appointments should be
scheduled through scheduled through scheduled through scheduled through scheduled through scheduled through
NationsHearing. NationsHearing. NationsHearing. NationsHearing. NationsHearing. NationsHearing.
Hearing aids $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 $1,000 (per ear) maximum
benefit every year. benefit every year. benefit every year. benefit every year. benefit every year. benefit every year.
All hearing aids must be All hearing aids must be All hearing aids must be All hearing aids must be All hearing aids must be All hearing aids must be
purchased through purchased through purchased through purchased through purchased through purchased through
NationsHearing. NationsHearing. NationsHearing. NationsHearing. NationsHearing. NationsHearing.
2
Benefits listed are for NEW
services received in-network Aetna Medicare Premier Aetna Medicare Advantra Aetna Medicare Value Plan Aetna Medicare Eagle (HMO) Aetna Medicare Premier 2 Aetna Medicare Premier 1
and per visit unless (HMO) Silver (PPO) (PPO) H0628-015 (PPO) (PPO)
otherwise stated H0628-005 H1608-029 H5521-088 Monthly Plan Premium: $0 H5521-020 H5521-134
Monthly Plan Premium: $0 Monthly Plan Premium: $0 Monthly Plan Premium: $0 Monthly Plan Premium: $124 Monthly Plan Premium: $140
Therapy
Physical and speech therapy $40 $40 $40 $25 $40 $40
Occupational therapy $40 $40 $40 $25 $40 $40
Ambulance
Ground ambulance (one-way $250 $350 $270 $250 $280 $270
trip)
Air ambulance (one-way trip) $250 $350 $270 $250 $280 $270
Additional benefits Aetna Medicare Premier Aetna Medicare Advantra Aetna Medicare Value Plan Aetna Medicare Eagle (HMO) Aetna Medicare Premier 2 Aetna Medicare Premier 1
(HMO) Silver (PPO) (PPO) H0628-015 (PPO) (PPO)
H0628-005 H1608-029 H5521-088 Monthly Plan Premium: $0 H5521-020 H5521-134
Monthly Plan Premium: $0 Monthly Plan Premium: $0 Monthly Plan Premium: $0 Monthly Plan Premium: $124 Monthly Plan Premium: $140
Fitness SilverSneakers® SilverSneakers® SilverSneakers® SilverSneakers® SilverSneakers® SilverSneakers®
Foot care (routine) $30 (six visits every year) $30 (six visits every year) $40 (six visits every year) $35 (twenty four visits every $40 (six visits every year) $30 (six visits every year)
year)
Help during a COVID-19 Public If a COVID-19 Public Health If a COVID-19 Public Health If a COVID-19 Public Health If a COVID-19 Public Health If a COVID-19 Public Health If a COVID-19 Public Health
Health Emergency Emergency is in effect, we Emergency is in effect, we Emergency is in effect, we Emergency is in effect, we Emergency is in effect, we Emergency is in effect, we
offer additional related offer additional related offer additional related offer additional related offer additional related offer additional related
services such as a package of services such as a package of services such as a package of services such as a package of services such as a package of services such as a package of
supplies to help prevent the supplies to help prevent the supplies to help prevent the supplies to help prevent the supplies to help prevent the supplies to help prevent the
spread of COVID-19 and assist spread of COVID-19 and assist spread of COVID-19 and assist spread of COVID-19 and assist spread of COVID-19 and assist spread of COVID-19 and assist
with recovery. with recovery. with recovery. with recovery. with recovery. with recovery.
Meals Up to 14 home delivered meals Not covered Up to 14 home delivered meals Up to 14 home delivered meals Not covered Not covered
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
Acute Hospital or Inpatient Acute Hospital or Inpatient Acute Hospital or Inpatient
Psychiatric Hospital to home. Psychiatric Hospital to home. Psychiatric Hospital to home.
Nursing Hotline $0 $0 $0 $0 $0 $0
Speak with a registered nurse Speak with a registered nurse Speak with a registered nurse Speak with a registered nurse Speak with a registered nurse Speak with a registered nurse
24 hours a day, 7 days a week 24 hours a day, 7 days a week 24 hours a day, 7 days a week 24 hours a day, 7 days a week 24 hours a day, 7 days a week 24 hours a day, 7 days a week
to discuss medical issues or to discuss medical issues or to discuss medical issues or to discuss medical issues or to discuss medical issues or to discuss medical issues or
wellness topics. wellness topics. wellness topics. wellness topics. wellness topics. wellness topics.
Over-the-counter items (OTC) $105 maximum benefit every $105 maximum benefit every $105 maximum benefit every $180 maximum benefit every Not covered Not covered
three months through CVS. three months through CVS. three months through CVS. three months through CVS.
Telehealth You can receive primary care You can receive primary care You can receive primary care You can receive primary care You can receive primary care You can receive primary care
and urgent care services and urgent care services and urgent care services and urgent care services and urgent care services and urgent care services
through a virtual visit for the through a virtual visit for the through a virtual visit for the through a virtual visit for the through a virtual visit for the through a virtual visit for the
same cost as an in-person same cost as an in-person same cost as an in-person same cost as an in-person same cost as an in-person same cost as an in-person
visit. visit. visit. visit. visit. visit.
Transportation $0 Not covered $0 Not covered Not covered Not covered
12 one-way trips every year. 12 one-way trips every year.
3
Additional benefits Aetna Medicare Premier Aetna Medicare Advantra Aetna Medicare Value Plan Aetna Medicare Eagle (HMO) Aetna Medicare Premier 2 Aetna Medicare Premier 1
(HMO) Silver (PPO) (PPO) H0628-015 (PPO) (PPO)
H0628-005 H1608-029 H5521-088 Monthly Plan Premium: $0 H5521-020 H5521-134
Monthly Plan Premium: $0 Monthly Plan Premium: $0 Monthly Plan Premium: $0 Monthly Plan Premium: $124 Monthly Plan Premium: $140
Visitor/travel benefit Allows members to receive Not covered Allows members to receive Allows members to receive Allows members to receive Allows members to receive
care at in-network cost shares care at in-network cost shares care at in-network cost shares care at in-network cost shares care at in-network cost shares
from Aetna Medicare from Aetna Medicare from Aetna Medicare from Aetna Medicare from Aetna Medicare
participating providers for up participating providers for up participating providers for up participating providers for up participating providers for up
to 12 months when outside the to 12 months when outside the to 12 months when outside the to 12 months when outside the to 12 months when outside the
service area. service area. service area. service area. service area.
Prescription drugs Aetna Medicare Premier Aetna Medicare Advantra Aetna Medicare Value Plan Aetna Medicare Eagle (HMO) Aetna Medicare Premier 2 Aetna Medicare Premier 1
(HMO) Silver (PPO) (PPO) H0628-015 (PPO) (PPO)
H0628-005 H1608-029 H5521-088 H5521-020 H5521-134
Preferred/Standard Preferred/Standard Preferred/Standard Preferred/Standard Preferred/Standard
Rx deductible $0 $150 $150 No Part D benefit $0 $150
Does not apply to Tier 1, Tier 2, Does not apply to Tier 1, Tier 2, Does not apply to Tier 1, Tier 2,
Tier 3 drugs. Tier 3 drugs. Tier 3 drugs.
Tier 1 Drugs:
• Retail Pharmacy: 30-day $2/$15 $5/$15 $0/$15 No Part D benefit $2/$15 $0/$15
supply
• Retail/Mail Pharmacy: $5/$45 $15/$45 $0/$45 $5/$45 $0/$45
90-day supply
Tier 2 Drugs:
• Retail Pharmacy: 30-day $5/$20 $7/$20 $5/$20 No Part D benefit $5/$20 $5/$20
supply
• Retail/Mail Pharmacy: $10/$60 $21/$60 $10/$60 $10/$60 $10/$60
90-day supply
Tier 3 Drugs:
• Retail Pharmacy: 30-day $47/$47 $47/$47 $47/$47 No Part D benefit $47/$47 $47/$47
supply
• Retail/Mail Pharmacy: $141/$141 $141/$141 $141/$141 $141/$141 $141/$141
90-day supply
Tier 4 Drugs:
• Retail Pharmacy: 30-day $100/$100 $100/$100 $100/$100 No Part D benefit $100/$100 $100/$100
supply
• Retail/Mail Pharmacy: $300/$300 $300/$300 $300/$300 $300/$300 $300/$300
90-day supply
Tier 5 Drugs:
• Retail Pharmacy: 30-day 33%/33% 30%/30% 30%/30% No Part D benefit 33%/33% 30%/30%
supply
• Retail/Mail Pharmacy: N/A N/A N/A N/A N/A
90-day supply
Gap coverage Yes Yes Yes No Part D benefit Yes Yes
Tier 1 & 2 Tier 1 & 2 Tier 1 & 2 Tier 1 & 2 Tier 1 & 2
Members in our HMO plans must use plan providers except in emergency or urgent care situations or for out-of-area renal dialysis or other services. If you obtain routine care from out-of-network providers, neither Medicare nor
Aetna will be responsible for the costs. Members in our HMO POS/PPO plans can go to doctors, specialists or hospitals in or out-of-network. With the exception of emergency or urgent care, it may cost more to get care from
out-of-network providers. Aetna Medicare is a HMO, PPO plan with a Medicare contract. Our SNPs also have contracts with State Medicaid programs. Enrollment in our plans depends on contract renewal. See Evidence
of Coverage for a complete description of plan benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by service area. Out-of-network/non-contracted providers are under no
4 PG21-OH01-CLEVELAND-AKRON-CANTON-YOUNGSTOWN-OH
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