Page 106 - Cover Letter and Evaluation for Paul Dorroh

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Zip Code: 30002
Current Coverage: Original Medicare
Current Subsidy: No Extra Help [?]
Select the tabs below for more detailed information about the plan health benefits,
drug costs and more coverage and star ratings. Drug List ID: 5957753248
Password Date: 04/13/2018
Important Coverage Information

Symbols

A process through which the physician or other health care provider is required to obtain advance approval from the
plan that payment will be made for a service or item furnished to an enrollee. Unless specified otherwise with respect
to a particular item or service, the enrollee is not responsible for obtaining (prior) authorization.

Some Dental Coverage Some Vision Coverage Some Hearing Coverage
* Estimated

Aetna Medicare Essential P.O. Box 14088 Overall Star Rating: [?] Enroll
Plan (PPO) Lexington, KY 40512
(H5521-091-0) Members: 4 out of 5 stars
1-800-282-5366
Organization: Aetna Medicare 711 (TTY/TDD)
Plan Type: Local Preferred
Provider Organization Non Members:
1-855-338-7027
711 (TTY/TDD)

Benefits Highlights
Monthly health plan premium $0.00

Health plan deductible $0

Other health plan deductibles?
In-Network: No

Maximum out-of-pocket enrollee $10,000 In and Out-of-network
responsibility (does not include $5,900 In-network
prescription drugs)
Optional supplemental benefits [?] No

Inpatient hospital coverage
In-Network: $285 for days 1 through 7
$0 for days 8 through 90
Out-of-Network: 40% per stay

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