2022 Aetna Medicare Select Plan (HMO) - H3312-002-0 In NY Plan ...

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2026 Medicare Advantage Plan Benefit Details for the Aetna Medicare Select Plan (HMO) - H3312-002-0
2026 Medicare Advantage Plan Details
Medicare Plan Name:Aetna Medicare Signature (HMO)
Location:Kings, New York Click to see other locations
Plan ID:H3312 - 002 - 0 Click to see other plans
Member Services:(833)570-6670 TTY users 711
Medicare Contact Information:Please visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) for information on all of your options. TTY users 1-877-486-2048or contact your local SHIP for assistance
Email a copy of the Aetna Medicare Signature (HMO) benefit details
— Medicare Plan Features —
Monthly Premium:$0.00 (see Plan Premium Details below)
Annual Rx Deductible:$615 (Tier 1 and 2 excluded from the Deductible.)
Health Plan Type:HMO
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$9,250
Drug Benefit Type ❔Enhanced Alternative (EA)
Total Number of Formulary Drugs:3,664 drugsBrowse the Aetna Medicare Signature (HMO) Formulary
Formulary Exception Tier:Tier 4 If your formulary exception request is approved, your drug will be placed on this tier.
This plan has 5 drug tiers. See cost-sharing for all pharmacies and tiers.
Insulin on a Medicare Part D plan's formulary will have a monthly copay of $35 or less.
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
• Preferred Pharmacy Cost-Sharing during initial coverage phase:$0.00$0.0024%25%25%
• Number of Drugs per Tier:4748974301078785
Plan's Pharmacy Search:http://www.aetnamedicare.com/findpharmacy
Plan Offers Mail Order?Yes
Medicare Plan Pharmacy Numbers: BIN: 610502 PCN: MEDDAET See BIN/PCNs for all plans
Number of Members enrolled in this plan in Kings, New York:3,988 members
Number of Members enrolled in this plan in (H3312 - 002):5,836 members
Plan’s Summary Star Rating: 3 out of 5 Stars.
• Customer Service Rating: 5 out of 5 Stars.
• Member Experience Rating: 3 out of 5 Stars.
• Drug Cost Accuracy Rating: 4 out of 5 Stars.
— Plan Premium Details —
The Monthly Premium is Split as Follows: ❔TotalPremiumPart CPremiumPart D BasicPremiumPart D SupplementalPremium
$0.00$0.00$0.00$0.00
Part D Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ $0.00
Total Monthly Premium with LIS (Parts C & D): $0.00
— Plan Health Benefits —
** Base Plan **
Premium
• Total monthly premium: $0.00
• Health plan premium: $0.00
• Drug plan premium: $0.00
• You must continue to pay your Part B premium.
• Part B premium reduction: No
Deductible
• Health plan deductible: In-network deductible: $0
• Drug plan deductible: $615.00 annual deductible
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $9,250 In-network
Optional supplemental benefits
• One package available. See below
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
• In-network: Yes, contact plan for further details.
Doctor visits
• Primary: $5 copay
• Specialist: $0-$50 copay
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures: $0-$50 copay (authorization required)
• Lab services: $0-$10 copay (authorization required)
• Diagnostic radiology services (e.g., MRI): $0-$325 copay (authorization required)
• Outpatient x-rays: $50 copay (authorization required)
Emergency care/Urgent care
• Emergency: $115 copay (always covered)
• Urgent care: $40 copay (always covered)
Inpatient hospital coverage
• $399 per day for days 1 through 6$0 per day for days 7 through 90 (authorization required)
Outpatient hospital coverage
• $0-$395 copay per visit (authorization required)
Skilled Nursing Facility
• Coming soon.
Preventive care
• $0 copay
Ground ambulance
• $265 copay
Rehabilitation services
• Occupational therapy visit: $35 copay
Mental health services
• Inpatient hospital - psychiatric: $346 per day for days 1 through 6$0 per day for days 7 through 90 (authorization required)
• Outpatient group therapy visit with a psychiatrist: $45 copay (authorization required)
• Outpatient individual therapy visit with a psychiatrist: $45 copay (authorization required)
• Outpatient group therapy visit: $45 copay (authorization required)
• Outpatient individual therapy visit: $45 copay (authorization required)
Medical equipment/supplies
• Durable medical equipment (e.g., wheelchairs, oxygen): 0%-20% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs): 20% coinsurance per item (authorization required)
• Diabetes supplies: 0%-20% coinsurance per item (authorization required)
Hearing
• Hearing exam: $50 copay
• Fitting/evaluation: $0 copay (limits apply)
• Hearing aids: $0-$1,700 copay (limits apply)
• Hearing aids - inner ear: Not covered
• Hearing aids - outer ear: Not covered
• Hearing aids - over the ear: Not covered
• Hearing aids - over the counter (OTC): Not covered
Medicare covered dental services
• $50 copay (authorization required)
Preventive dental
• Office visit: Coming soon
• Oral exam: $0 copay (limits apply)
• Cleaning: $0 copay (limits apply)
• Fluoride treatment: Not covered
• Dental x-ray(s): $0 copay (limits apply)
• Other diagnostic dental services: Not covered
• Other preventive dental services: Not covered
Comprehensive dental
• Restorative services: Not covered
• Endodontics: Not covered
• Periodontics: Not covered
• Prosthodontics, removable: Not covered
• Prosthodontics, fixed: Not covered
• Maxillofacial Prosthetics: Not covered
• Oral and Maxillofacial Surgery: Not covered
• Implant Services: Not covered
• Orthodontics: Not covered
• Adjunctive General Services: Not covered
Vision
• Routine eye exam: MC: $0-$50 copay NMC: $0 copay (limits apply)
• Other: $0 copay
• Contact lenses: $0 copay (limits apply)
• Eyeglasses (frames and lenses): $0 copay (limits apply)
• Eyeglass frames: $0 copay (limits apply)
• Eyeglass lenses: $0 copay (limits apply)
• Upgrades: $0 copay (limits apply)
Medically-approved non-opioid pain management services
• Chiropractic services: MC: $15 copay NMC: Not covered (limits may apply; authorization or referral may be required)
• Acupuncture: Some coverage
• Therapeutic Massage: Not covered
• Alternative Therapies: Not covered
More benefits
• Transportation services: Not covered
• Over-the-counter drug benefits: Not covered
• Meals for short duration: Some coverage
• Annual physical exams: Some coverage
• Telehealth: Some coverage
• WorldWide emergency transportation: Some coverage
• WorldWide emergency coverage: Some coverage
• WorldWide emergency urgent care: Some coverage
• Fitness Benefit: Some coverage
• In-Home Support Services: Not covered
• Bathroom Safety Devices: Not covered
• Health Education: Some coverage
• In-Home Safety Assessment: Not covered
• Personal Emergency Response System (PERS): Not covered
• Medical Nutrition Therapy (MNT): Not covered
• Post discharge In-Home Medication Reconciliation: Not covered
• Re-admission Prevention: Not covered
• Wigs for Hair Loss Related to Chemotherapy: Some coverage
• Weight Management Programs: Not covered
• Adult Day Health Services: Not covered
• Nutritional/Dietary Benefit: Not covered
• Home-Based Palliative Care: Not covered
• Support for Caregivers of Enrollees: Not covered
• Additional Sessions of Smoking and Tobacco Cessation Counseling: Some coverage
• Enhanced Disease Management: Not covered
• Telemonitoring Services: Not covered
• Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline): Some coverage
• Counseling Services: Not covered
Transportation
• Not covered
Foot care (podiatry services)
• Foot exams and treatment: MC: $50 copay
• Routine foot care: Not covered
Medicare Part B drugs
• Part B Insulin drugs: $35 copay (authorization required)
• Chemotherapy: 0%-20% coinsurance (authorization required)
• Other Part B drugs: 0%-20% coinsurance (authorization required)
** Optional Supplemental Benefit Packages **
Package #1
• Description: Deluxe Comprehensive Dental Package
** Optional Supplemental Benefits **
• Monthly Premium: $34
• Deductible: none
• Maximum Benefit: none
• Package benefits include: Restorative Services; Endodontics; Periodontics; Prosthodontics, removable; Prosthodontics, fixed; Oral and Maxillofacial Surgery; Adjunctive General Services;

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