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Aetna Medicare Premier (PPO) - H5521-245-000

4.5 out of 5 stars* for plan year 2025

$0.00

Monthly Premium

Aetna Medicare Premier (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna Inc.

Plan ID: H5521-245-000

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$0.00

Monthly Premium

South Carolina 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 South Carolina 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

CoverageDetails
Monthly plan premium$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$250.00
Out-of-pocket maximum$6,750.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$2,000.00
Primary care doctor visit$0 in-network
$10 out-of-network
Specialty doctor visitIn-Network
$0 for services provided in a nursing home
$35 for services provided outside a nursing home

Out-of-Network
$45
Inpatient hospital care$350 per day, days 1-8; $0 per day, days 9-90 in-network
$474 per day, days 1-8; $0 per day, days 9-90 out-of-network
Urgent care
Urgent Care:
Copayment for Urgent Care $45

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $100
Maximum Plan Benefit of $250,000
Emergency room visit$100 If you are admitted to the hospital within 0 hours your cost share may be waived
Ambulance transportation$275 in-network
$275 out-of-network

Health Care Services and Medical Supplies

Aetna Medicare Premier (PPO) covers a range of additional benefits. Learn more about Aetna Medicare Premier (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

CoverageDetails
Chiropractic services
Out-of-Network:

Medicare Covered Chiropractic Services:
Coinsurance for Medicare Covered Chiropractic Services 20%
Diabetes supplies, training, nutrition therapy and monitoringIn-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 equipment (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-raysLab Services: In-Network
$0

Out-of-Network
20%
Diagnostic Procedures: In-Network
$0 for certain Medicare-covered diagnostic tests and services including Retinal fundus, Spirometry, Peripheral arterial disease (PAD)

$0 for services provided by your primary care physician in their office
$120 for services performed by a provider other than your primary care physician

Out-of-Network
20%
Imaging: Xray: $0 for services provided by your primary care physician in their office in-network; $14 for services performed by a provider other than your primary care physician in-network
CT Scans: $0 for services provided by your primary care physician in their office in-network; $200 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; $200 for services performed by a provider other than your primary care physician in-network
Diagnostic Radiology Mammogram: $0 in-network
20% out-of-network
Home health care$0 in-network
20% out-of-network
Mental health inpatient care
Out-of-Network:

Psychiatric Hospital Services:
Coinsurance for Psychiatric Hospital per Stay 20%
Mental health outpatient careIn-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
20% for Mental Health Services- Group Sessions
20% for Mental Health Services - Individual Sessions
20% for Psychiatric Services - Group Sessions
20% for Psychiatric Services - Individual Sessions
Outpatient services/surgeryAmbulatory Surgical Center: In-Network
$0 for preventive and diagnostic colonoscopy
$274 all other ambulatory surgical center services

Out-of-Network
$374
Outpatient substance abuse care
Out-of-Network:

Medicare Covered Outpatient Substance Abuse Services:
Coinsurance for Medicare Covered Individual Sessions 20%
Coinsurance for Medicare Covered Group Sessions 20%
Over-the-counter itemsOver-the-Counter (OTC) Wallet with a $45 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 servicesIn-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $10
Skilled Nursing Facility (SNF) care$10 per day, days 1-20; $214 per day, days 21-100 in-network
20% per stay out-of-network

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Dental careIn-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

$2,000 benefit amount (allowance) every year in and out-of-network for covered preventive and comprehensive dental services.

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

CoverageDetails
Vision careIn-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:
$45 for Medicare-covered eye exams
$45 for non-Medicare covered eye exams
(Maximum one non-Medicare covered eye exam every year in or out-of-network)

Eyewear:
20% 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

$160 benefit amount (allowance) reimbursement 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.

CoverageDetails
Hearing careIn-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
$1,250 benefit amount (allowance) per ear, every year for hearing aids
(Maximum two hearing aids every year)

Out-of-Network:

Hearing Exams:
$45 for Medicare-covered hearing exams
$45 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, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Preventive services and health/wellness education programsIn-Network
$0 copay for all preventive services covered under Original Medicare

Out-of-Network
$0 for all preventive services covered under Original Medicare

Prescription Drug Costs and Coverage

The Aetna Medicare Premier (PPO) offers prescription drug coverage, with an annual drug deductible of $250.00 (excludes Tiers 1 and 2)

Coverage & Cost
Coverage
Cost
Annual drug deductible$250.00 (excludes Tiers 1 and 2)
Tier 1
  • Preferred retail $0.00
  • Standard retail $2.00
  • Preferred mail order $0.00
  • Standard mail order $2.00
Tier 2
  • Preferred retail $10.00
  • Standard retail $12.00
  • Preferred mail order $10.00
  • Standard mail order $12.00
Annual drug deductible$250.00 (excludes Tiers 1 and 2)
Tier 1
  • Preferred retail $0.00
  • Standard retail $4.00
  • Preferred mail order $0.00
  • Standard mail order $4.00
Tier 2
  • Preferred retail $20.00
  • Standard retail $24.00
  • Preferred mail order $20.00
  • Standard mail order $24.00
Annual drug deductible$250.00 (excludes Tiers 1 and 2)
Tier 1
  • Preferred retail $0.00
  • Standard retail $6.00
  • Preferred mail order $0.00
  • Standard mail order $6.00
Tier 2
  • Preferred retail $30.00
  • Standard retail $36.00
  • Preferred mail order $20.00
  • Standard mail order $36.00

When reviewing South Carolina 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 South Carolina 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

South Carolina Counties Served

We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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