02 Aetna Medicare 2015 Benefits at a Glance Colorado Aetna Medicare SM Plan (HMO) (PPO) Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas, Jefferson Compare our medical and prescription drug coverage in your area 58.02.395.1-CO1A Contact us for answers to your questions or to enroll: 1-855-338-7027 (TTY: 711), 8 a.m. to 8 p.m., seven days a week, from October 1 February 14; 8 a.m. to 8 p.m., Monday Friday, from February 15 September 30. Or visit: http://www.aetnamedicare.com The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or copayments/coinsurance may change on January 1 of each year. For a complete description of benefits, exclusions, limitations and conditions of coverage, refer to the Evidence of Coverage. Y0001_4030_3529a_FINAL_24a Accepted 8/2014
03 Aetna Medicare Plan (HMO) Aetna Medicare Prime Plan (HMO) Monthly Plan Premium $0.00 Medical Coverage 1 Preventive care (Annual wellness visits, vaccines and flu shots covered by Medicare. Routine physical exam covered by Aetna.) Primary care doctor visits $5 copay Specialist doctor visits $40 copay Inpatient hospital care (unlimited inpatient days) $289 copay per day, day(s) 1-6 Outpatient surgery $264 copay Emergency care (worldwide coverage) $65 copay (waived if admitted) Urgently-needed care $40 copay Lab services Diagnostic tests $40 copay at primary care doctor office $40 copay at all other locations Diagnostic X-ray services $5 copay at primary care doctor office $40 copay at all other locations Diagnostic radiology services 20% coinsurance Therapeutic radiology services 20% coinsurance Annual in-network maximum out-of-pocket amount 2 $5,900 Dental coverage Eyewear coverage Hearing aids coverage Fitness benefit (for membership at participating fitness facilities) Prescription Drug Coverage 3 Annual drug deductible $0 One-month supply from retail or mail-order network pharmacy Tier 1 Preferred generic Tier 2 Non-preferred generic Tier 3 Preferred brand Tier 4 Non-preferred brand Tier 5 Specialty Gap coverage One-month supply from retail or mail-order 5 network pharmacy Catastrophic coverage Retail and prescription mail order Pharmacy network 6 Formulary name Saver Formulary 2 4,5 $8 copay 4,5 $45 copay 50% coinsurance You will pay 45% on brand drugs and only 65% of the costs of generic drugs. The greater of $2.65 copay for generic drugs (including brand drugs treated as generic), $6.60 copay for all other covered drugs OR 5% coinsurance. Saver
Aetna Medicare Select Plan (HMO) $55.00 $25 copay $50 copay $289 copay per day, day(s) 1-6 $264 copay $65 copay (waived if admitted) $50 copay $25 copay at primary care doctor office $50 copay at all other locations $25 copay at primary care doctor office $50 copay at all other locations 20% coinsurance 20% coinsurance $6,000 $500 every year Up to $125 every year Up to $500 every year $0 $0 or $4 copay 4,5 $8 or $12 copay 4,5 $45 copay 50% coinsurance 33% coinsurance You will pay 45% on brand drugs and only 65% of the costs of generic drugs. The greater of $2.65 copay for generic drugs (including brand drugs treated as generic), $6.60 copay for all other covered drugs OR 5% coinsurance. Standard Preferred Standard Formulary 2 All-in-one Medicare plan Our Aetna Medicare Advantage plans offer combined medical and prescription drug coverage. Once you ve enrolled, there s just one phone number to call if you need help. Plus, we offer online options to reduce paperwork. If you receive more than one service during a single visit, you generally pay only one copay (the highest copay from all services during your single visit). In addition, if any of the services during the same visit have a coinsurance, you will pay the coinsurance amount for each service. Access to select providers Our Prime network HMO plan offers you an affordable monthly premium. You have access to a network of local providers. In a Prime HMO plan, you must use network providers, except in emergency or urgent care situations, or for out-of-area renal dialysis. 04
05 Access to many hospitals, doctors and specialists Our plans offer you access to a large number of doctors and hospitals locally or around the country where these plans are available. With most Aetna Medicare Plans (HMO), you can enroll in our U.S. Travel Advantage program* at no cost to you. You ll get the same benefits you receive at home when you travel to any service area approved by the plan and use a doctor or hospital in the Aetna Medicare network. This means if you re traveling or away from home, you ll pay your network cost if an Aetna Medicare HMO or PPO network provider is available. Our plans also cover you for urgent and emergency medical care 24 hours a day, 7 days a week, anywhere in the world. Finding a doctor or hospital is easy Visit http://www.aetnamedicaredocfind.com Call us at 1-855-338-7027 (TTY: 711) Access to preferred pharmacies in your network Our plans offer you access to preferred pharmacies that are contracted to provide you with reduced cost sharing. This means your copay/coinsurance for a drug at a preferred pharmacy will be lower than what you would pay at a standard pharmacy within the same network. Find the drugs you need in our formulary Our formulary is a list of drugs we cover. It includes many of the most commonly prescribed generic and brand-name drugs. You'll find generic drugs at the lowest cost in Tier 1. And you'll pay less than $10 for most of them. Costlier generic drugs appear in higher tiers. But we may have a lower-cost option for some of them in a lower tier. Choosing one of these less-expensive drugs helps you save more at the pharmacy. Start each year with a physical exam An extensive physical assessment starts by collecting your medical history. Then you will get a full body exam. You have coverage for an annual physical exam every 12 months. You can control your high blood pressure If you have high blood pressure, we can help you. Once you re diagnosed with high blood pressure, we ll contact you. And if you choose to enroll in our hypertension program, we ll: Send you a blood pressure cuff at no cost to you Offer calls that remind you to enter your blood pressure into an automated system Support you by assigning you a case manager, if needed * HMO members may be required to enroll in the U.S. Travel Advantage program prior to seeking care out of their service area. See your EOC for details. Prime Network HMO plans do not have access to U.S. Travel Advantage program.
06 Optional supplemental coverage available with select Aetna Medicare Plans (HMO) Some of our plans give you the option to select supplemental benefits coverage, such as certain dental services plus eyewear and hearing aids reimbursement. Please keep in mind there will be an additional monthly premium if you enroll in supplemental coverage. You must select a participating primary care dentist from our Dental Maintenance Organization (DMO ) network to coordinate dental care. Dental services must be provided by the selected primary care dentist. Aetna Medicare Advantage Dental Plan (HMO) Aetna Medicare Advantage Dental Plan (HMO) Plus Eyewear and Hearing Aids Additional monthly plan premium $12.40 per month $22.40 per month Plans with coverage Per-visit dental copay for covered services Covered dental services (partial list) Reduced-fee dental services** (partial list) Covered/reduced-fee dental services received out of network Aetna Medicare Prime Plan (HMO) $5 $5 Aetna Medicare Prime Plan (HMO) Oral and emergency exams, cleanings, oral hygiene consultation, X-rays, restorative care: retention pins, fillings, minor dental adjustments, periodontic care: scaling and root planing Crown, bridges, dentures, root canals, oral surgery, including non-surgical extractions, periodontic care: maintenance and surgeries Not covered with HMO plans Not covered with HMO plans Eyewear coverage Up to $125 a year Hearing aids coverage Up to $300 a year ** For reduced-fee costs, go to http://www.aetnamedicare.com.
07 Aetna Medicare Plan (PPO) Aetna Medicare Prime Plan (PPO) Monthly Plan Premium $48.00 Medical Coverage Preventive care (Annual wellness visits, vaccines and flu shots covered (network) by Medicare. Routine physical exam covered by Aetna.) Primary care doctor visits $5 copay (network) Specialist doctor visits $30 copay (network) Inpatient hospital (unlimited inpatient days) $289 copay per day, day(s) 1-6 (network) Outpatient surgery $200 copay (network) Emergency care (worldwide coverage) $65 copay (waived if admitted) Urgently-needed care $30 copay Lab services (network) / 40% coinsurance (out of network) Diagnostic tests $5 copay at primary care doctor office; $30 copay at all other locations (network) Diagnostic X-ray services $5 copay at primary care doctor office (network); $30 copay at all other locations (network) Diagnostic radiology services 20% coinsurance (network) Therapeutic radiology services 20% coinsurance (network) Annual in-network (IN) maximum out-of-pocket (OOP) amount 7 $6,700 Annual out-of-network (OON) deductible $750 Annual combined IN and OON maximum OOP amount 7 $10,000 Dental coverage Eyewear coverage Hearing aids coverage Fitness benefit (for membership at participating fitness facilities) Prescription Drug Coverage 3 Annual drug deductible $0 One-month supply from retail or mail-order network pharmacy Tier 1 Preferred generic Tier 2 Non-preferred generic Tier 3 Preferred brand Tier 4 Non-preferred brand Tier 5 Specialty Gap coverage One-month supply from retail or mail-order 5 network pharmacy Catastrophic coverage Retail and prescription mail order 4,5 $8 copay 4,5 $45 copay 50% coinsurance Pharmacy network 6 Formulary name Saver Formulary 2 You will pay 45% on brand drugs and only 65% of the costs of generic drugs. The greater of $2.65 copay for generic drugs (including brand drugs treated as generic), $6.60 copay for all other covered drugs OR 5% coinsurance. Saver
Aetna Medicare Select Plan (PPO) 08 $122.00 (network) $25 copay (network) $50 copay (network) $289 copay per day, day(s) 1-6 (network) $245 copay (network) $65 copay (waived if admitted) $50 copay (network) / $25 copay at primary care doctor office; $50 copay at all other locations (network) $25 copay at primary care doctor office (network); $50 copay at all other locations (network) 20% coinsurance (network) 20% coinsurance (network) $6,700 $750 $10,000 $500 every year Up to $125 every year Up to $500 every year $0 Flexibility in choosing doctors and hospitals With an Aetna Medicare Plan (PPO), you have the flexibility to choose doctors and hospitals both in and out of our network. You may save money by staying within the network. Although you are not required to select a primary care doctor, you are encouraged to do so. You ll benefit by having a doctor who can coordinate your care and help you with important medical decisions. Remember, you are covered when you visit a doctor or hospital outside the Aetna PPO network. However, you may pay more, except in emergencies. For example, if you visit a specialist who is in our network, you pay your plan s set copay. If you visit a specialist who is outside our network, you pay a percentage (coinsurance). This may be higher than your network copay. Please note, whether in or out of network, your doctor must accept Medicare for services to be covered. Access to select providers Our Prime network PPO plan offers you an affordable monthly premium. You have access to a network of local providers. With the Prime PPO plan, you have the flexibility to choose doctors and hospitals both in and out of our Prime network. But you ll save money by using a network provider. $3 or $7 copay 4,5 $11 or $15 copay 4,5 $45 copay 50% coinsurance 33% coinsurance You will pay 45% on brand drugs and only 65% of the costs of generic drugs. The greater of $2.65 copay for generic drugs (including brand drugs treated as generic), $6.60 copay for all other covered drugs OR 5% coinsurance. Standard Preferred Standard Formulary 2
09 1 In an Aetna Medicare health maintenance organization (HMO) plan, you must use network providers, except in emergency or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers, neither Medicare nor Aetna will be responsible for the costs. You ll also need to select a primary care doctor to coordinate your care. A referral is required from your primary care doctor for specialty care. 2 The maximum out of pocket (MOOP) is a limit to how much you have to pay out of pocket each year for medical services in network that are covered under Medicare Part A and Part B. This protects you by limiting the total amount you will have to spend. The amounts you pay for copays and coinsurance for network-covered services count toward this MOOP amount. The amounts you pay for plan premiums (if applicable), Part D prescription drugs and some services do not count toward your MOOP amount. These services are noted in the Evidence of Coverage (EOC). 3 Beneficiaries must use network pharmacies to access their prescription drug benefit, except in non-routine circumstances. Pharmacy clinical programs, such as prior authorization, step therapy, and quantity limits, may apply to your prescription drug coverage. 4 Copays at preferred and/or standard pharmacies. 5 Aetna Rx Home Delivery delivers prescriptions to your door 6 May include access to preferred pharmacies in your network. Refer to the Summary of Benefits for plan details. 7 The maximum out of pocket (MOOP) is a limit to how much you have to pay out of pocket each year for medical services in network that are covered under Medicare Part A and Part B. This protects you by limiting the total amount you will have to spend. The in-network MOOP amount counts toward the combined in and out of network MOOP amount. The amounts you pay for copays and coinsurance for network-covered services count toward this MOOP amount. The amounts you pay for plan premiums (if applicable), Part D prescription drugs and some services do not count toward your MOOP amount. These services are noted in the Evidence of Coverage.