Page 78 - Cover Letter and Evaluation for Mike Peaseley

11/17/2017 Your Medicare Health Plan Details

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Your Plan Details

Zip Code: 98499
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: 6951340928
and more coverage and star ratings.
Password Date: 11/16/2017
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.
A process through which the enrollee’s primary care physician or other network physician (depending on the plan policy) permits or
instructs the enrollee to obtain an item or service from another physician or other provider type.
Some Vision Coverage Some Hearing Coverage
* Estimated

Aetna Medicare Value Plan P.O. Box 14088 Overall Star Rating: [?] Enroll
Lexington, KY 40512
(HMO)
(H3931-126-0) Members: 3.5 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)

Benefits Highlights
Monthly health plan premium $0.00

Health plan deductible $0

Other health plan deductibles?
In-Network: No

Maximum out-of-pocket enrollee $6,500 In-network
responsibility (does not include
prescription drugs)
Optional supplemental benefits [?] No
Inpatient hospital coverage $360 for days 1 through 5
$0 for days 6 through 90

Outpatient hospital coverage $45-255 per visit

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