Aetna Medicare Premier (PPO)
Aetna Medicare Premier (PPO) H5521-110 Plan Details
Aetna Medicare Premier (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5521-110
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.
$31.00
Monthly Premium
Aetna Medicare Premier (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5521-110
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 Premier (PPO) H5521-110 Plan Details
Aetna Medicare Premier (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H5521-110
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.
$31.00
Monthly Premium
New York Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $450 |
| Out of Pocket Max |
In-Network: $9350 Out-of-Network: N/A |
| Initial Coverage Limit | $2000 |
| Catastrophic Coverage Limit | $2,000 |
| Primary Care Doctor Visit | $0 in-network|$50 out-of-network |
| Specialty Doctor Visit | In-Network|$0 for services provided in a nursing home|$40 for services provided outside a nursing home||Out-of-Network|$60 |
| Inpatient Hospital Care | $390 per day, days 1-5; $0 per day, days 6-90 in-network|$500 per day, days 1-20; $0 per day, days 21-90 out-of-network |
| Urgent Care | Copayment for Urgent Care $45 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $110 |
| Emergency Room Visit | $110 If you are admitted to the hospital within 0 hours your cost share may be waived |
| Ambulance Transportation | $300 in-network|$300 out-of-network |
Health Care Services and Medical Supplies
Aetna Medicare Premier (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|40% |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | Lab Services: In-Network|$0 ||Out-of-Network|40% Diagnostic Procedures: In-Network|$0 for certain Medicare-covered diagnostic tests and services including Retinal fundus, Spirometry, Peripheral arterial disease (PAD)||$40 for other diagnostic procedures and tests||Out-of-Network|40% Imaging: Xray: $40 in-network|CT Scans: $175 for CT/CAT scans in-network; $250 for all other complex imaging in-network|Diagnostic Radiology other than CT Scans: $175 for CT/CAT scans in-network; $250 for all other complex imaging in-network|Diagnostic Radiology Mammogram: $0 in-network|40% out-of-network |
| Home Health Care | $0 in-network|40% out-of-network |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $374 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|$40 for Mental Health: Group Sessions|$40 for Mental Health: Individual Sessions|$40 for Psychiatric Services: Group Sessions|$40 for Psychiatric Services: Individual Sessions||Out-of-Network|30% for Mental Health Services- Group Sessions|40% for Mental Health Services - Individual Sessions|30% for Psychiatric Services: Group Sessions|40% for Psychiatric Services: Individual Sessions |
| Outpatient Services / Surgery | Ambulatory Surgical Center: In-Network|$0 for preventive and diagnostic colonoscopy|$250 all other ambulatory surgical center services||Out-of-Network|40% |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $40 Copayment for Medicare-covered Group Sessions $40 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 40% Coinsurance for Medicare Covered Group Sessions 30% |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $40 Out-of-Network: Medicare Covered Podiatry Services: Copayment for Medicare Covered Podiatry Services $60 |
| Skilled Nursing Facility Care | $0 per day, days 1-20 $195 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:|20% for oral exams|20% for cleanings|20% for fluoride treatments|20% for x-rays|20% for other diagnostic dental services|20% for other preventive dental services||Comprehensive dental services:|20% for restorative services|20% for endodontic services|20% for periodontic services|20% for removeable prosthodontics|20% for fixed prosthodontics|20% for oral and maxillofacial surgery|20% for adjunctive services||$1,000 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|$40 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:|$60 for Medicare-covered eye exams|$60 for non-Medicare covered eye exams|(Maximum one non-Medicare covered eye exam every year in or out-of-network)||Eyewear:|30% 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||$150 benefit amount (allowance) reimbursement 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:|$40 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-$1,700 for hearing aids|(Maximum two hearing aids every year)||Out-of-Network:||Hearing Exams:|$60 for Medicare-covered hearing exams|$60 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 Premier (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $450 (excludes Tiers 1 and 2) per year.
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
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| Annual Drug Deductible | $450 (excludes Tiers 1 and 2) |
| Preferred Generic |
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| Generic |
|
| Annual Drug Deductible | $450 (excludes Tiers 1 and 2) |
| Preferred Generic |
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| Generic |
|
| Annual Drug Deductible | $450 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
