Page 114 - Cover Letter and Evaluation for John

10/9/2018 Your Medicare Health Plan Details

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Your Plan Details

Zip Code: 92586
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: 3199691584
and more coverage and star ratings. Password Date: 10/09/2018

Important Coverage Information

You are now viewing 2019 plan data. View 2018 plan data.

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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, 2018
Plan (PPO)

(H5521-126-0) Members:
1-800-282-5366
Organization: Aetna Medicare 711 (TTY/TDD)

Plan Type: Local Preferred Non Members:
Provider Organization 1-833-859-6031
711 (TTY/TDD)

Benefits Highlights

Monthly health plan premium $41.40

Health plan deductible $750 annual deductible

Other health plan deductibles?
In-Network: No

Maximum out-of-pocket enrollee $10,000 In and Out-of-network
responsibility (does not include $6,700 In-network
prescription drugs)
Optional supplemental benefits [?] Yes

Additional benefits and/or reduced cost-
sharing for enrollees with certain health In-Network: No
conditions?

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