Aetna Medicare Premier Plus PPO Plans

Are you exploring the Aetna Medicare Premier Plus PPO and need straightforward answers? This plan offers not just the usual medical coverage for 2025, but the added benefit of choice—see any doctor and access extra services like dental and mental health care, with clear, simple copayments and coinsurance.

Understand here what Aetna Medicare Premier Plus PPO means for you: freedom, comprehensive care, and manageable costs, without the complexity.

 

Key Takeaways

 

  • Out-of-pocket costs for Aetna Medicare Premier Plus PPO plan members include structured copayments for various services, with the plan detailing costs for in-network and out-of-network visits, as well as coinsurance after deductibles are met.

 

  • Additional features of the Aetna Medicare Premier Plus PPO plan include comprehensive dental and vision care, extensive prescription drug coverage, wellness programs, and annual updates on plan changes to keep members informed about their benefits.

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Understanding Aetna Medicare Premier Plus PPO

Flexibility is a vital element in healthcare. The Aetna Medicare Premier Plus PPO plan offers just that. The plan gives you the option to see any doctor, including podiatry services, whether they are within or outside the provider network, as long as they accept Medicare and the plan’s terms. This flexibility allows you to choose the best healthcare provider for your needs, without being confined to a specific network.

Additionally, The Aetna Medicare Premier Plus PPO plan stands out from other Medicare options in terms of coverage. It offers:

 

  • Basic Medicare coverage
  • Dental benefits
  • Mental health services
  • Preventive services such as oral exams and cleanings

 

Understanding Aetna Medicare Premier Plus PPO

This means that you will have access to a wide range of healthcare services, beyond just the basics.

Regarding costs, the Aetna Medicare Premier Plus PPO plan has a clear and straightforward structure. Here are the costs for different types of visits:

 

  • In-network primary care doctor visits: $0 copayment
  • In-network specialist visits: $20 copayment
  • Out-of-network primary care doctor visits: $10 copayment
  • Out-of-network specialist visits: $30 copayment
  • Emergency care: $100 copayment per visit
  • Urgent care: $20 copayment per visit

 

As for durable medical equipment, there may be specific copayments or coinsurance, depending on the plan.

 

Network Freedom and Provider Choice

Aetna Medicare Premier Plus PPO plans offer:

 

  • A comprehensive network of healthcare providers
  • Network freedom, allowing you to access healthcare providers both within and outside the Aetna provider network
  • The flexibility to choose any provider that accepts Medicare and complies with the plan’s terms without the requirement of a referral
  • Tools to help you locate and select doctors within the plan’s coverage network, making it easier for you to manage your healthcare.

 

However, be aware that selecting providers outside the network may result in increased out-of-pocket expenses and restrictions on coverage for specific services or supplies.

 

Coverage Beyond Basics

Aetna Medicare Premier Plus PPO plans extend beyond basic Medicare coverage, offering additional dental and vision benefits. For dental coverage, the plan includes preventive services like cleanings, oral exams, and X-rays. Additionally, certain plans may also provide comprehensive dental coverage.

 

Aetna medicare premier (ppo)

 

 

As for vision benefits, the plan includes:

 

  • An annual eye examination
  • Coverage for prescription eyewear such as glasses and contact lenses
  • An examination for diabetic retinopathy, which is covered under Medicare Part B

 

These additional benefits ensure that you receive comprehensive healthcare coverage.

 

Prescription Drug Benefits

Prescription drug coverage is an integral part of any healthcare plan. The Aetna Medicare Premier Plus PPO plan provides access to an extensive array of medications as part of its prescription drug benefits. The key features of the plan’s prescription drug coverage include:

 

  • Access to a wide range of medications
  • Coverage for both brand-name and generic drugs
  • Convenient mail-order pharmacy option
  • $6,350 out-of-pocket threshold for prescription drugs

 

Moreover, members enrolled in the plan can access generic drugs and certain brand-name drugs at no copay. The plan categorizes prescription drugs into various tiers within its formulary (drug list), helping you easily identify the cost of your prescribed medications.

Cost and Savings: Analyzing Your Expenses

It’s vital for efficient financial planning to understand your healthcare expenses. The Aetna Medicare Premier Plus PPO plan offers zero copay options for all preventive services covered under Original Medicare, allowing you to maintain your health without worrying about copayments.

However, there may be supplementary cost-sharing expenses linked to the plan. These include:

 

 

Once the deductible is met, you are required to cover a percentage of healthcare expenses, known as coinsurance, until your out-of-pocket maximum is reached. This coinsurance can influence your healthcare costs and should be considered when planning your healthcare expenses.

 

Zero Copay Advantage

The Aetna Medicare Premier Plus PPO plan offers a Zero Copay Advantage. All preventive services covered under Original Medicare have a $0 copay and zero cost sharing. This means you won’t have to pay anything for these services.

This means that you can access specific services, including:

 

  • Preventive care
  • Prescription drugs
  • Dental care
  • Vision care

 

Without the requirement of paying a copayment, resulting in additional cost savings.

However, it’s important to realize that this advantage has exceptions for specific direct access services. Most services require the utilization of network providers, except in cases of emergency or urgent care, and for out-of-network services.

 

Understanding Cost Sharing and Coinsurance

Cost sharing refers to the portion of healthcare expenses for which the individual is accountable, which includes mechanisms like coinsurance. In the Aetna Medicare Premier Plus PPO plan, the calculation of coinsurance involves determining a percentage of the cost of a covered service that the individual pays after meeting the deductible.

For instance, if a service is priced at $100 and the coinsurance rate is 20%, the individual would pay $20 after fulfilling the deductible requirement.

Certain services such as Continuous Glucose Monitors (CGMs) and their supplies, as well as specific preventive services, necessitate cost sharing under the plan.

 

Monthly Premiums and Plan Deductible

To effectively manage your healthcare costs, it’s vital to understand monthly premiums and plan deductibles. The monthly premiums for Aetna Medicare Premier Plus PPO vary from $0.00 to $34.00, contingent upon the particular plan.

The cost of these premiums is influenced by factors such as included deductibles, copayments, and coinsurance costs.

The deductible represents the initial amount that an individual is responsible for paying for covered services before the plan commences coverage. Once the deductible is met, the individual will be responsible for a percentage of the healthcare services cost.

Apart from the monthly premium and plan deductible, there could be additional expenses in Aetna Medicare Premier Plus PPO plans, such as copays and coinsurance.

Enhanced Services and Special Features

Aetna Medicare Premier Plus PPO plan provides:

 

  • Comprehensive dental and vision care
  • Wellness programs
  • Consistently maintains a rating of 4 stars or above, demonstrating strong adherence to quality measures and high performance.

 

Comprehensive Dental and Vision Care

The Aetna Medicare Premier Plus PPO plans encompass dental services including:

 

  • Oral exams
  • Cleanings
  • X-rays
  • Fillings
  • Root canals
  • Extractions
  • Dentures
  • Crowns
  • Bridges
  • Implants

 

However, the Aetna Medicare Premier Plus PPO plan does impose a benefit maximum for dental coverage, with a range of approximately $150 to $6,000. Furthermore, there is an annual cap of $2,000 for dental services, and any costs exceeding this limit are the responsibility of the individual.

 

Aetna medicare premier plus (ppo benefits)

 

 

In addition, the vision benefits included in Aetna Medicare Premier Plus PPO plans encompass:

 

  • An annual eye examination
  • Coverage for prescription eyewear such as glasses and contact lenses
  • An examination for diabetic retinopathy, which is covered under Medicare Part B.

 

Wellness Programs and Additional Benefits

Members of the Aetna Medicare Premier Plus PPO plan have access to the following fitness benefits, exercise, and physical activity programs at no extra cost:

 

  • Wellness initiatives that improve overall health
  • Programs that promote the adoption of healthy habits, such as maintaining a balanced diet and engaging in regular exercise
  • Initiatives designed to mitigate the risk of chronic health conditions
  • Programs that alleviate stress

 

These initiatives are aimed at improving the health and well-being of plan members.

Accessing these wellness programs and additional benefits can be achieved by utilizing the online health tools provided by Aetna for its members. These tools provide comprehensive information about your benefits and coverage, including access to a detailed drug list and personalized healthcare resources.

 

Star Ratings and Quality Measures

Ensuring that the healthcare plan you select provides high-quality services is paramount. The Star Ratings signify that Aetna Medicare Premier Plus PPO plans have achieved a rating of 4 stars or higher, showcasing a dedication to delivering high-quality care.

These ratings are determined by considering a range of critical factors that assess the excellence and efficacy of Medicare Advantage and Medicare Part D plans.

These factors include beneficiary experiences, healthcare outcomes, and plan effectiveness. The plan’s overall performance and quality are also determined by HEDIS Measurements.

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Inpatient and Specialist Care Considerations

In healthcare, every detail is significant. The Aetna Medicare Premier Plus PPO offers coverage for inpatient hospital care, including stays in psychiatric hospitals. This ensures that you are covered for any necessary inpatient care.

 

Inpatient Hospital Coverage

The expense for inpatient hospital care is:

 

  • $335 per day for days 1-6 in-network
  • No cost for days 7-90 in-network
  • $500 per day for days 1-20 out-of-network
  • No charge for days 21-90 out-of-network

 

Furthermore, there are no restrictions on the number of days covered for hospital stays under the Aetna Medicare Premier Plus PPO plan. This flexibility allows you to focus on your recovery without worrying about the costs associated with an extended hospital stay.

 

Access to Specialists Without Referrals

The Aetna Medicare Premier Plus PPO plan provides coverage for members to consult any specialist who accepts Medicare and adheres to the plan’s terms, whether they are in or out of the network. This means you have the freedom to consult a specialist that best suits your healthcare needs, without the need for a referral.

 

Aetna premier plus ppo summary of benefits 2024

 

 

This policy improves convenience by eliminating the requirement for primary care physician referrals, saving you time and facilitating quicker access to specialized care.

 

Skilled Nursing Facility Benefits

Skilled nursing facility benefits are another crucial aspect of the Aetna Medicare Premier Plus PPO plan. The plan provides coverage for services that require administration by a registered nurse or licensed practical (vocational) nurse.

The Aetna Medicare Premier Plus PPO plan provides coverage for skilled nursing facility benefits at $0 per day for days 1-20 and $203 per day thereafter. However, be aware that there are limitations or exclusions for skilled nursing facility benefits under the plan, including that most services necessitate the use of network providers, except in cases of emergency or urgent care.

Navigating Plan Changes and Updates

Keeping abreast of changes to your healthcare plan is essential for effective healthcare management. The Aetna Medicare Premier Plus PPO plan updates their plans annually, with modifications detailed in the Annual Notice of Change (ANOC).

 

Annual Benefits Update

Keeping track of annual benefits updates in Aetna Medicare Premier Plus PPO is essential because it allows individuals to stay informed about the available benefits, which in turn can contribute to maintaining their health effectively.

Annual updates to the Aetna Medicare Premier Plus PPO plan undergo regular annual updates, with modifications detailed in the Annual Notice of Change (ANOC).

To remain informed about these updates, it’s advisable to regularly review your plan documents, such as the Summary of Benefits, Evidence of Coverage, Formulary, and Annual Notice of Change.

 

Making Changes During Enrollment Periods

The enrollment period for Aetna Medicare Premier Plus PPO usually spans from October 15 to December 7 annually. During this period, individuals have the option to modify their coverage or enroll in a health care or prescription drug plan.

It’s important to have your Medicare Parts A and B enrollment information, contact details, and details pertaining to the changes you intend to make on hand when making changes to your plan.

 

Staying Informed About Plan Evolution

Keeping up-to-date with the evolution of your plan is key to optimizing your healthcare experience. Aetna Medicare Premier Plus PPO updates their plans annually.

Aetna informs members about modifications or updates to their Premier Plus PPO plan through their office manual, office link updates, and plan documents such as the Summary of Benefits, Evidence of Coverage, Formulary, and Annual Notice of Change.

Aetna also offers resources and tools to aid members in understanding changes to the Medicare Premier Plus PPO plan, ensuring you’re always up-to-date with your coverage benefits.

Maximizing Your Healthcare Experience

Coordinating your care is vital to maximize your healthcare experience, utilize mail order services, and access support resources.

 

 

Aetna medicare premier plus ppo providers

 

 

The Aetna Medicare Premier Plus PPO plan offers a range of resources to help you manage your health effectively.

 

Coordinating Care and Services

The Aetna Medicare Premier Plus PPO plan offers:

 

  • Case management programs that support members in adopting evidence-based treatments
  • Access to Original Medicare
  • Supplementary services such as unlimited hospital stays and preventive care.

 

These programs offer additional assistance and support, ultimately resulting in a cost-efficient resolution for healthcare requirements.

 

Utilizing Mail Order for Convenience

Utilizing mail order services for prescription delivery can make managing your prescriptions more convenient. The Aetna Medicare Premier Plus PPO plan offers a mail order service that allows you to:

 

  • Have your prescriptions filled through CVS Caremark® Mail Service Pharmacy
  • Access the service with no additional cost
  • Enjoy standard shipping at no extra charge.

 

This means that you can have your medications delivered directly to your home or a location of your choice.

 

Support Resources for Members

Support resources are crucial to enhancing your healthcare experience. The Aetna Medicare Premier Plus PPO plan provides support resources including:

 

  • Fast referrals to local services through Resources For Living
  • Community resource help
  • Care management support
  • Online health tools

 

These resources can help you manage your health outcomes, offering assistance that caters to your specific needs.

Summary

In conclusion, the Aetna Medicare Premier Plus PPO plan offers a comprehensive range of benefits, from the flexibility to choose any healthcare provider to extensive coverage beyond basic Medicare.

The plan also offers additional benefits such as preventive dental and vision care, wellness programs, and high-quality performance as reflected in the star ratings. With the plan’s zero copay options, clear cost-sharing structure, and options for inpatient and specialist care, you’re assured of a plan that caters to your healthcare needs.

Stay informed about your plan’s updates and evolution, and maximize your healthcare experience by coordinating care, utilizing mail order services, and accessing support resources.

Frequently Asked Questions

 

 

Is Aetna Medicare PPO the same as Medicare Advantage?

No, the Aetna Medicare PPO is not the same as Medicare Advantage. It offers comprehensive coverage in one plan.

 

What is the payer ID for Aetna Medicare Premier PPO?

The payer ID for Aetna Medicare Premier PPO is # 60054. All claims should be submitted using this electronic payer ID and mailed to the address on the back of the member’s ID card.

 

What is the difference between Medicare and PPO?

The main difference between Medicare and PPO is that while Medicare Advantage Plans, including PPOs, must provide the same benefits as Original Medicare, they may do so with different rules, restrictions, and costs.

PPOs also offer additional benefits such as vision and hearing care. This provides more flexibility to see providers outside the network compared to Medicare HMOs.

 

What does the Aetna Medicare Premier Plus PPO plan offer in terms of flexibility?

The Aetna Medicare Premier Plus PPO plan offers flexibility by allowing members to see any doctor, including podiatry services, within or outside the provider network as long as they accept Medicare and the plan’s terms.

 

What additional coverage does the Aetna Medicare Premier Plus PPO plan offer?

The Aetna Medicare Premier Plus PPO plan offers additional coverage including dental benefits, mental health services, and preventive services such as oral exams and cleanings, going beyond basic Medicare coverage.

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 ZRN Health & Financial Services, LLC, a Texas limited liability company

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Speak with a licensed insurance agent

 1-833-641-4938
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Mon-Fri : 8am-9pm EST

Russell Noga
( Medicare Expert )

Russell Noga is the CEO of ZRN Health & Financial Services, and head content editor of several Medicare insurance online publications. He has over 15 years of experience as a licensed Medicare insurance broker helping Medicare beneficiaries learn about Medicare, Medicare Advantage Plans, Medigap insurance, and Medicare Part D prescription drug plans.