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9/12/2017 Your Medicare Health Plan Details

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Your Plan Details

Zip Code: 90049
Current Coverage: Original Medicare
Current Subsidy: No Extra Help [?]
Select the tabs below for more detailed information about the plan health benefits, drug costs Drug List ID: 0226651648
and more coverage and star ratings.
Password Date: 09/12/2017
Important Coverage Information

Symbols

Some Vision Coverage Some Hearing Coverage
* Estimated

Aetna Medicare Choice P.O. Box 14088 Overall Star Rating: [?] Enroll
Lexington, KY 40512
Plan (PPO)
(H5521-125-0) Members: 4 out of 5 stars
1-800-282-5366
Organization: Aetna Medicare 711 (TTY/TDD)
Plan Type: Non Members:
1-855-338-7027
711 (TTY/TDD)

Costs and Other Important Information

Monthly Health Plan Premium $60.40
Monthly Drug Plan Premium $12.60

Health Plan Deductible $750 annual deductible

Other Health Plan Deductibles? No
Maximum Out-of-Pocket Enrollee Responsibility (does not $10,000 In and Out-of-network
include prescription drugs) $6,700 In-network
[?]
Prescription Drugs Covered? Yes

Choice of Doctors? Any Doctor
Optional Supplemental Benefits? No

Benefits

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H5521&plnid=125&sgmntid=0#plan_benefits 1/2