Page 68 - Cover Letter and Evaluation for Mike Peaseley

11/17/2017 Your Medicare Health Plan Comparison
Vision Aetna Medicare Choice Plan (PPO) Aetna Medicare Select Plan (PPO)

Routine eye exam In-Network: $0 copay In-Network: $0 copay
Out-of-Network: 45% Out-of-Network: 40%
There may be limits on how much the plan There may be limits on how much the plan
will provide. will provide.
Other Not covered Not covered
Contact lenses In-Network: $0 copay In-Network: $0 copay
Out-of-Network: $0 copay Out-of-Network: $0 copay
There may be limits on how much the plan There may be limits on how much the plan
will provide. will provide.
Eyeglasses (frames and lenses) In-Network: $0 copay In-Network: $0 copay
Out-of-Network: $0 copay Out-of-Network: $0 copay
There may be limits on how much the plan There may be limits on how much the plan
will provide. will provide.
Eyeglass frames In-Network: $0 copay In-Network: $0 copay
Out-of-Network: $0 copay Out-of-Network: $0 copay
There may be limits on how much the plan There may be limits on how much the plan
will provide. will provide.
Eyeglass lenses In-Network: $0 copay In-Network: $0 copay
Out-of-Network: $0 copay Out-of-Network: $0 copay
There may be limits on how much the plan There may be limits on how much the plan
will provide. will provide.
Upgrades Not covered Not covered
Optional Supplemental Benefits

Aetna Medicare Choice Plan (PPO) Aetna Medicare Select Plan (PPO)

Package #1 Comprehensive dental services, Preventive dental services Not Available
Monthly Premium: $20.00
Deductible: $50.00
Package #2 Comprehensive dental services, Hearing aids, Preventive dental Not Available
services
Monthly Premium: $23.00
Deductible: $50.00
Drug Plan Information

Outpatient Prescription Aetna Medicare Choice Plan (PPO) Aetna Medicare Select Plan (PPO)
Drugs
Monthly Premium $24.60 $26.50
Deductible $0 $0
Formulary Website View formulary website  View formulary website 
Initial Coverage Phase Aetna Medicare Choice Plan (PPO) 1 Aetna Medicare Select Plan (PPO) 1

Tier 1 1 (Preferred Generic) 1 (Preferred Generic)
Preferred Retail Preferred Retail
1-Month: $0.00 copay 1-Month: $0.00 copay
3-Month: $0.00 copay 3-Month: $0.00 copay
All: Not Available All: Not Available
Standard Retail Standard Retail
1-Month: $10.00 copay 1-Month: $10.00 copay
3-Month: $30.00 copay 3-Month: $30.00 copay
All: Not Available All: Not Available
Preferred Mail Order Preferred Mail Order
1-Month: $0.00 copay 1-Month: $0.00 copay
3-Month: $0.00 copay 3-Month: $0.00 copay
All: Not Available All: Not Available
Standard Mail Order Standard Mail Order
1-Month: $10.00 copay 1-Month: $10.00 copay
3-Month: $30.00 copay 3-Month: $30.00 copay
All: Not Available All: Not Available

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