Page 72 - Cover letter and evaluation for Michele Buros

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Zip Code: 15146
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: 2133754848
Password Date: 02/21/2018
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 Gold Plan P.O. Box 14088 Overall Star Rating: [?] Enroll
(PPO) Lexington, KY 40512
(H5521-122-0) 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 $130.90
Health plan deductible $500 annual deductible

Other health plan deductibles?
In-Network: No

Maximum out-of-pocket enrollee $7,500 In and Out-of-network
responsibility (does not include $4,500 In-network
prescription drugs)
Optional supplemental benefits [?] No

Inpatient hospital coverage
In-Network: $300 per stay
Out-of-Network: 20% per stay

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