Aetna Medicare Advantra Silver (PPO)
Aetna Medicare Advantra Silver (PPO) H5522-004 Plan Details
Aetna Medicare Advantra Silver (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5522-004
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
$0.00
Monthly Premium
Aetna Medicare Advantra Silver (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5522-004
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
Aetna Medicare Advantra Silver (PPO) H5522-004 Plan Details
Aetna Medicare Advantra Silver (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5522-004
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
$0.00
Monthly Premium
Pennsylvania Counties Served
Huntingdon
Blair
Potter
Northampton
Lehigh
Carbon
Schuylkill
Monroe
Luzerne
Lackawanna
Susquehanna
Wyoming
Sullivan
Fulton
Cumberland
Clinton
York
Juniata
Lycoming
Tioga
Bradford
Mifflin
Dauphin
Perry
Lebanon
Snyder
Adams
Berks
Lancaster
Wayne
Montour
Union
Northumberland
Centre
Franklin
Pike
Columbia
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $590 |
| Out of Pocket Max |
In-Network: $7500 Out-of-Network: N/A |
| Initial Coverage Limit | $2000 |
| Catastrophic Coverage Limit | $2,000 |
| Primary Care Doctor Visit | $0 in-network|40% out-of-network |
| Specialty Doctor Visit | In-Network|$0 for services provided in a nursing home|$35 for services provided outside a nursing home||Out-of-Network|40% |
| Inpatient Hospital Care | $275 per day, days 1-5; $0 per day, days 6-90 in-network|40% per stay out-of-network |
| Urgent Care | Copayment for Urgent Care $45 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $110 Maximum Plan Benefit of $150,000 |
| Emergency Room Visit | $110 If you are admitted to the hospital within 24 hours your cost share may be waived |
| Ambulance Transportation | $275 in-network|$275 out-of-network |
Health Care Services and Medical Supplies
Aetna Medicare Advantra Silver (PPO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
| Coverage | Cost |
|---|---|
| Chiropractic Services | In-Network: Copayment for Medicare-covered Chiropractic Services $15 Out-of-Network: Medicare Covered Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 40% |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network|0% for OneTouch/LifeScan diabetic supplies|20% for other covered diabetic supplies||Out-of-Network|0% for OneTouch/LifeScan diabetic supplies|20% for other covered diabetic supplies |
| Durable Medical Eqipment (DME) | In-Network|0% for continuous glucose monitors|20% for all other Medicare-covered DME items||Out-of-Network|20% |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | Lab Services: In-Network|$0 ||Out-of-Network|40% Diagnostic Procedures: In-Network|$0||Out-of-Network|40% Imaging: Xray: $30 in-network|CT Scans: $0 for services provided by your primary care physician in their office in-network; $295 for services performed by a provider other than your primary care physician in-network|Diagnostic Radiology other than CT Scans: $0 for services provided by your primary care physician in their office in-network; $295 for services performed by a provider other than your primary care physician in-network|Diagnostic Radiology Mammogram: $0 in-network|40% out-of-network |
| Home Health Care | $0 in-network|$0 out-of-network |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $350 per day for days 1 to 5 $0 per day for days 6 to 90 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required Out-of-Network: Psychiatric Hospital Services: Coinsurance for Psychiatric Hospital per Stay 40% |
| Mental Health Outpatient Care | In-Network|$35 for Mental Health: Group Sessions|$35 for Mental Health: Individual Sessions|$35 for Psychiatric Services: Group Sessions|$35 for Psychiatric Services: Individual Sessions||Out-of-Network|45% for Mental Health Services- Group Sessions|45% for Mental Health Services - Individual Sessions|45% for Psychiatric Services: Group Sessions|45% for Psychiatric Services: Individual Sessions |
| Outpatient Services / Surgery | Ambulatory Surgical Center: In-Network|$0 for preventive and diagnostic colonoscopy|$225 all other ambulatory surgical center services||Out-of-Network|40% |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $35 Copayment for Medicare-covered Group Sessions $35 Prior Authorization Required for Outpatient Substance Abuse Services Prior authorization required Out-of-Network: Medicare Covered Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual Sessions 45% Coinsurance for Medicare Covered Group Sessions 45% |
| Over-the-counter (OTC) Items | $75 quarterly benefit amount (allowance) to purchase approved over-the-counter (OTC) health and wellness products. Approved items can be purchased online, in store, or by phone. Unused benefit amounts do not rollover. |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $35 Copayment for Routine Foot Care $35
Out-of-Network: Medicare Covered Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 40% Non-Medicare Covered Podiatry Services: Coinsurance for Non-Medicare Covered Podiatry Services 40% |
| Skilled Nursing Facility Care | $0 per day, days 1-20 $214 per day, days 21-100 in-network|40% per stay out-of-network |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network||Preventive dental services:|$0 for oral exams|$0 for cleanings|$0 for fluoride treatment|$0 for x-rays|$0 for other diagnostic dental services|$0 for other preventive dental services||Comprehensive dental services:|$0 for restorative services|$0 for endodontic services|$0 for periodontic services|$0 for removeable prosthodontics|$0 for fixed prosthodontics|$0 for oral and maxillofacial surgery|$0 for adjunctive services||Out-of-Network||Preventive dental services:|50% for oral exams|50% for cleanings|50% for fluoride treatments|50% for x-rays|50% for other diagnostic dental services|50% for other preventive dental services||Comprehensive dental services:|50% for restorative services|50% for endodontic services|50% for periodontic services|50% for removeable prosthodontics|50% for fixed prosthodontics|50% for oral and maxillofacial surgery|50% for adjunctive services||$850 benefit amount (allowance) every year in and out-of-network for covered preventive and comprehensive dental services. Medical necessity requirements vary by covered dental service.||ADA recognized dental services are covered up to the benefit amount excluding implants and related services, orthodontics, cosmetic services, those considered medical in nature, and administrative charges. See EOC for a full list of exclusions. |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network||Eye Exams:|$0 for Diabetic eye exams|$35 for all other Medicare-covered eye exams|$0 for non-Medicare covered eye exams|(Maximum one non-Medicare covered eye exam every year in or out-of-network)||Eyewear:|$0 for Medicare-covered prescription eyewear|$0 for Contacts|$0 for Eyeglasses|$0 for Eyeglass Frames|$0 for Eyeglass Lenses|$0 for Upgrades||Out-of-Network||Eye Exams:|40% for Medicare-covered eye exams|40% for non-Medicare covered eye exams|(Maximum one non-Medicare covered eye exam every year in or out-of-network)||Eyewear:|40% 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||$200 benefit amount (allowance) every year for non-Medicare covered prescription eyewear. |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network||Hearing Exams:|$35 for Medicare-covered hearing exams|$0 for non-Medicare covered hearing exams|(Maximum one non-Medicare covered hearing exam every year in or out-of-network)|$0 for fitting/evaluation for hearing aids|(Maximum one hearing aid fitting/evaluation every year)||Hearing Aids:|$0 for hearing aids|$500 benefit amount (allowance) per ear, every year for hearing aids|(Maximum two hearing aids every year)||Out-of-Network:||Hearing Exams:|40% for Medicare-covered hearing exams|40% 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
The following services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Preventive Services and Health/Wellness Education Programs | In-Network|$0 copay for all preventive services covered under Original Medicare||Out-of-Network|0% for the pneumonia, influenza, Hepatitis B, and Covid-19 vaccines|40% for all other preventive services covered under Original Medicare |
Prescription Drug Costs and Coverage
The Aetna Medicare Advantra Silver (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $590 (excludes Tiers 1 and 2) per year.
| Coverage |
Cost
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|---|---|
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Coverage & Cost
|
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| Annual Drug Deductible | $590 (excludes Tiers 1 and 2) |
| Preferred Generic |
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| Generic |
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| Annual Drug Deductible | $590 (excludes Tiers 1 and 2) |
| Preferred Generic |
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| Generic |
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| Annual Drug Deductible | $590 (excludes Tiers 1 and 2) |
| Preferred Generic |
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| Generic |
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