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Aetna Medicare Advantra Philly Prime (HMO-POS) - H3959-053-000
$0.00
Monthly Premium
Aetna Medicare Advantra Philly Prime (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.
Plan ID: H3959-053-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
Pennsylvania Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.
Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.
Learn more about Pennsylvania Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Enrollment may be limited to certain times of the year. See why you may be able to enroll.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $0.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $590.00 |
| Out-of-pocket maximum | $6,900.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,000.00 |
| Primary care doctor visit | $0 |
| Specialty doctor visit | In-Network $45 |
| Inpatient hospital care | $325 per day, days 1-7; $0 per day, days 8-90 |
| Urgent care | 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 | $250 |
Health Care Services and Medical Supplies
Aetna Medicare Advantra Philly Prime (HMO-POS) covers a range of additional benefits. Learn more about Aetna Medicare Advantra Philly Prime (HMO-POS) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $15 Copayment for Routine Care $15
|
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network 0% for OneTouch/LifeScan diabetic supplies 20% for other covered diabetic supplies |
| Durable medical equipment (DME) | In-Network 0% for continuous glucose monitors 20% for all other Medicare-covered DME items |
| Diagnostic tests, lab and radiology services, and X-rays | Lab Services: In-Network $0 Diagnostic Procedures: In-Network $0 Imaging: Xray: $20 in-network CT Scans: $0 for services provided by your primary care physician in their office in-network; $250 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; $250 for services performed by a provider other than your primary care physician in-network Diagnostic Radiology Mammogram: $0 in-network |
| Home health care | $0 |
| 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 |
| Mental health outpatient care | In-Network $45 for Mental Health - Group Sessions $45 for Mental Health - 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 $250 all other ambulatory surgical center services |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $45 Copayment for Medicare-covered Group Sessions $45 Prior Authorization Required for Outpatient Substance Abuse Services |
| Over-the-counter items | Over-the-Counter (OTC) Wallet with a $75 quarterly benefit amount (allowance) on the Extra Benefits Card to purchase approved over-the-counter (OTC) health and wellness products like first aid supplies, cold and allergy medicine, pain relievers, and more. Approved products can be purchased in-store, online, or by phone. Unused benefit amounts do not rollover. |
| Podiatry services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $45 Copayment for Routine Foot Care $45
|
| Skilled Nursing Facility (SNF) care | $0 per day, days 1-20; $214 per day, days 21-100 in-network |
Dental Benefits
The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| 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 $1,500 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, though there may be provider network restrictions. See the plan Evidence of Coverage
| Coverage | Details |
|---|---|
| Vision care | In-Network Eye Exams: $0 for Diabetic eye exams $45 for all other Medicare-covered eye exams $0 for non-Medicare covered eye exams (Maximum one non-Medicare covered eye exam every year) Eyewear: $0 for Medicare-covered prescription eyewear $0 for Contacts $0 for Eyeglasses $0 for Eyeglass Frames $0 for Eyeglass Lenses $0 for Upgrades $350 benefit amount (allowance) every year for non-Medicare covered prescription eyewear. |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | In-Network Hearing Exams: $45 for Medicare-covered hearing exams $0 for non-Medicare covered hearing exams (Maximum one non-Medicare covered hearing exam every year) $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) |
Preventive Services and Health/Wellness Education Programs
The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Preventive services and health/wellness education programs | In-Network $0 copay for all preventive services covered under Original Medicare |
Prescription Drug Costs and Coverage
The Aetna Medicare Advantra Philly Prime (HMO-POS) offers prescription drug coverage, with an annual drug deductible of $590.00 (excludes Tiers 1 and 2)
Coverage & Cost | |
|---|---|
| Coverage | Cost |
| Annual drug deductible | $590.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
|
| Annual drug deductible | $590.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
|
| Annual drug deductible | $590.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
|
When reviewing Pennsylvania Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.
You may be able to find plans in your part of Pennsylvania that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Plan Documents
| Links to plan documents |
Pennsylvania Counties Served
Enrolling in H3959-053-000 Medicare Advantage Plans in Pennsylvania
Medicare beneficiaries from Pennsylvania may have access to Medicare Advantage plans from Aetna and other insurance companies.
Get help comparing your local plan options by calling to speak with a licensed insurance agent who can help you find out if your doctor and prescription drugs are covered by a Medicare Advantage plan in your area.
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.