Page 82 - Cover Letter & Evaluation for Isaac Kapon

10/5/2017 Your Medicare Health Plan Details

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Your Plan Details
Zip Code: 89014
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: 1485169984
Password Date: 10/05/2017
Important Coverage Information

You are now viewing 2018 plan data. View 2017 plan data.

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 Choice P.O. Box 14088 Overall Star Rating: [?] Enrollment begins
Lexington, KY 40512 Coming Soon October 15, 2017
Plan (PPO)
(H5521-055-0) 1 Members:
1-800-282-5366
Organization: Aetna Medicare 711 (TTY/TDD)
Plan Type: Non Members:
1-855-338-7027
711 (TTY/TDD)

Additional Plan Information

Overall Star Rating [?] Coming Soon

Health Plan Star Ratings [?] Coming Soon

Drug Plan Star Ratings [?] Coming Soon

Plan Type: Local Preferred Provider Organization
Plan Status: Approved by Medicare
Area: Clark County

View plan website 
Important Note:
This plan does not charge an annual deductible for all drugs. The $75.00 annual deductible only applies to drugs on certain tiers.
This plan's deductible only applies to out-of-network services.

Provider Network: 2501-3000 physicians and providers.
View provider and physician network website 

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H5521&plnid=055&sgmntid=0 1/2