Aetna Medicare

Aetna Medicare Plan (PPO) 2023 Schedule of Cost Sharing

Aetna Medicare

Former Employer/Union/Trust Name: CITY OF NEW YORK

Group Agreement Effective Date: 09/01/2023

This Schedule of Cost Sharing is part of the Evidence of Coverage for Aetna Medicare Plan (PPO). When

the Evidence of Coverage refers to the document with information on health care benefits covered under

our plan, it is referring to this Medical Benefits Chart. (See Chapter 4, Medical Benefits Chart (What is

covered and what you pay).) If you have questions, please call our Member Services at the telephone

number printed on your member ID card or call our general Member Services at 1‑855‑648‑0389. (TTY

users should call 711.) Hours are 8 AM to 9 PM ET, Monday through Friday.

Annual Deductible FOR SERVICES RECEIVED

IN‑NETWORK &

OUT‑OF‑NETWORK COMBINED

This is the amount you have to pay out‑of‑pocket before the

plan will pay its share for your covered Medicare Part A and B

services.

No Deductible 09/01/23–12/31/23.

$150 calendar year deductible

01/01/24–12/31/24.

Annual Maximum Out‑of‑Pocket Limit FOR SERVICES RECEIVED

IN‑NETWORK & OUT‑OF‑NETWORK

COMBINED

The maximum out‑of‑pocket limit is the most you will pay for

covered Medicare Part A and B services, including any

deductible (if applicable).

$1,500

Y0001_EGWP_SOC

GRP_SOC_2023_T1_31912-13

Master Plan ID: CY31912-13

Aetna Medicare Plan (PPO) 2023 Schedule of Cost Sharing

Important information regarding the services listed below in the Schedule of Cost Sharing:

If you receive services from: If your plan

services include:

You will pay:

Copays only One PCP copay.

Copays and

coinsurance

The PCP copay and the

coinsurance amounts for each

service.

A primary care physician (PCP):

Family Practitioner•

Pediatrician•

Internal Medicine•

General Practitioner•

And get more than one covered service during

the single visit:

Coinsurance only The coinsurance amounts for all

services received.

Copays only The highest single copay for all

services received.

Copays and

coinsurance

The highest single copay for all

services and the coinsurance

amounts for each service.

An outpatient facility, specialist or doctor who

is not a PCPand get more than one covered

service during the single visit:

Coinsurance only The coinsurance amounts for all

services received.

Aetna Medicare Plan (PPO) 2023 Schedule of Cost Sharing

Medical Benefits Chart

You will see this apple next to the preventive services in the benefits chart.

Services that are covered for you

What you must pay when you get these

services

Abdominal aortic aneurysm screening

A one‑time screening ultrasound for people at risk. The

plan only covers this screening if you have certain risk

factors and if you get a referral for it from your physician,

physician assistant, nurse practitioner, or clinical nurse

specialist.

There is no coinsurance, copayment, or

deductible for members eligible for this

preventive screening.

Acupuncture for chronic low back pain

Covered services include:

Up to 12 visits in 90 days are covered for Medicare

beneficiaries under the following circumstances:

For the purpose of this benefit, chronic low back pain is

defined as:

Lasting 12 weeks or longer;•

nonspecific, in that it has no identifiable systemic

cause (i.e., not associated with metastatic,

inflammatory, infectious, etc. disease);

•

not associated with surgery; and•

not associated with pregnancy.•

An additional eight sessions will be covered for those

patients demonstrating an improvement. No more than

20 acupuncture treatments may be administered

annually.

Treatment must be discontinued if the patient is not

improving or is regressing.

Provider Requirements:

Physicians (as defined in 1861(r)(1) of the Social Security

Act (the Act)) may furnish acupuncture in accordance

with applicable state requirements.

Physician assistants (PAs), nurse practitioners

(NPs)/clinical nurse specialists (CNSs) (as identified in

1861(aa)(5) of the Act), and auxiliary personnel may

furnish acupuncture if they meet all applicable state

requirements and have:

a masters or doctoral level degree in acupuncture

or Oriental Medicine from a school accredited by

•

$15 copay for each Medicare‑covered

acupuncture visit.

Aetna Medicare Plan (PPO) 2023 Schedule of Cost Sharing

Services that are covered for you

What you must pay when you get these

services

the Accreditation Commission on Acupuncture and

Oriental Medicine (ACAOM); and,

a current, full, active, and unrestricted license to

practice acupuncture in a State, Territory, or

Commonwealth (i.e., Puerto Rico) of the United

States, or District of Columbia.

•

Auxiliary personnel furnishing acupuncture must be

under the appropriate level of supervision of a physician,

PA, or NP/CNS required by our regulations at 42 CFR

§§410.26 and 410.27.

Ambulance services

Covered ambulance services include fixed wing,

rotary wing, and ground ambulance services, to the

nearest appropriate facility that can provide care

only if they are furnished to a member whose

medical condition is such that other means of

transportation could endanger the person’s health

or if authorized by the plan.

•

Non‑emergency transportation by ambulance is

appropriate if it is documented that the member’s

condition is such that other means of transportation

could endanger the person’s health and that

transportation by ambulance is medically required.

•

$0 copay for each Medicare‑covered

one‑way trip via ground or air ambulance.

Annual routine physical

The annual routine physical is an extensive physical exam

including a medical history collection and it may also

include any of the following: vital signs, observation of

general appearance, a head and neck exam, a heart and

lung exam, an abdominal exam, a neurological exam, a

dermatological exam, and an extremities exam.

Coverage for this non‑Medicare covered benefit is in

addition to the Medicare‑covered annual wellness visit

and the “Welcome to Medicare” preventive visit. You may

schedule your annual routine physical once each

calendar year.

Preventive labs, screenings, and/or diagnostic tests

received during this visit are subject to your lab and

diagnostic test coverage. Please see “Outpatient

diagnostic tests and therapeutic services and

supplies” for more information.

$0 copay for an annual routine physical

exam.

Aetna Medicare Plan (PPO) 2023 Schedule of Cost Sharing

Services that are covered for you

What you must pay when you get these

services

Annual wellness visit

If you’ve had Part B for longer than 12 months, you can

get an annual wellness visit to develop or update a

personalized prevention plan based on your current

health and risk factors. Our plan will cover the annual

wellness visit once each calendar year.

Note:Your first annual wellness visit can’t take place

within 12 months of your “Welcome to Medicare”

preventive visit. However, you don’t need to have had a

“Welcome to Medicare” visit to be covered for annual

wellness visits after you’ve had Part B for 12 months.

There is no coinsurance, copayment, or

deductible for the annual wellness visit.

Bone mass measurement

For qualified individuals (generally, this means people at

risk of losing bone mass or at risk of osteoporosis), the

following services are covered every 24 months or more

frequently if medically necessary: procedures to identify

bone mass, detect bone loss, or determine bone quality,

including a physician’s interpretation of the results.

There is no coinsurance, copayment, or

deductible for Medicare‑covered bone mass

measurement.

Breast cancer screening (mammograms)

Covered services include:

One baseline mammogram between the ages of 35

and 39

•

One screening mammogram each calendar year

for women aged 40 and older

•

Clinical breast exams once every 24 months•

There is no coinsurance, copayment, or

deductible for covered screening

mammograms.

$0 copay for each diagnostic mammogram.

Cardiac rehabilitation services

Comprehensive programs of cardiac rehabilitation

services that include exercise, education, and counseling

are covered for members who meet certain conditions

with a doctor’s order. The plan also covers intensive

cardiac rehabilitation programs that are typically more

rigorous or more intense than cardiac rehabilitation

programs.

$0 copay for each Medicare‑covered

cardiac rehabilitation visit.

$0 copay for each Medicare‑covered

intensive cardiac rehabilitation visit.

Cardiovascular disease risk reduction visit (therapy

for cardiovascular disease)

We cover one visit per year with your primary care doctor

to help lower your risk for cardiovascular disease. During

this visit, your doctor may discuss aspirin use (if

appropriate), check your blood pressure, and give you

tips to make sure you’re eating healthy.

There is no coinsurance, copayment, or

deductible for the intensive behavioral

therapy cardiovascular disease preventive

benefit.

Cardiovascular disease testing

There is no coinsurance, copayment, or

Aetna Medicare Plan (PPO) 2023 Schedule of Cost Sharing

Services that are covered for you

What you must pay when you get these

services

Blood tests for the detection of cardiovascular disease (or

abnormalities associated with an elevated risk of

cardiovascular disease) once every 5 years (60 months).

deductible for cardiovascular disease testing

that is covered once every 5 years.

Cervical and vaginal cancer screening

Covered services include:

For all women: Pap tests and pelvic exams are

covered once every 24 months

•

If you are at high risk of cervical or vaginal cancer

or you are of childbearing age and have had an

abnormal Pap test within the past 3 years: one Pap

test every 12 months

•

There is no coinsurance, copayment, or

deductible for Medicare‑covered preventive

Pap and pelvic exams.

Chiropractic services

Covered services include:

We cover only manual manipulation of the spine to

correct subluxation

•

$15 copay for each Medicare‑covered

chiropractic visit.

There is no coinsurance, copayment, or

deductible for a Medicare‑covered

colorectal cancer screening exam.

$0 copay for each Medicare‑covered

preventive barium enema.

If a polyp is removed or a biopsy is

performed during a Medicare‑covered

screening colonoscopy, the polyp removal

and associated pathology will be covered at

$0 copay as these procedures were

performed during a preventive service.

Diagnostic colonoscopy is covered at $0

copay when you schedule a diagnostic

colonoscopy after having a Guaiac‑based

fecal occult blood test (gFOBT) or Fecal

immunochemical test (FIT).

If you have had polyps removed during a

previous colonoscopy or have a condition

that is monitored via colonoscopy (such as a

prior history of colon cancer), ongoing

colonoscopies are considered diagnostic,

and are subject to the outpatient surgery

cost‑sharing.

Colorectal cancer screening

For people 50 and older, the following are covered:

Flexible sigmoidoscopy (or screening barium

enema as an alternative) every 48 months

•

Two of each of the following per calendar year:

Guaiac‑based fecal occult blood test (gFOBT)•

Fecal immunochemical test (FIT)•

DNA based colorectal screening every 3 years

For people at high risk of colorectal cancer, we cover:

Screening colonoscopy (or screening barium

enema as an alternative) every 24 months

•

For people not at high risk of colorectal cancer, we cover:

Screening colonoscopy every 10 years (120

months), but not within 48 months of a screening

sigmoidoscopy

•

Aetna Medicare Plan (PPO) 2023 Schedule of Cost Sharing

Services that are covered for you

What you must pay when you get these

services

(See “Outpatient surgery, including

services provided at hospital outpatient

facilities and ambulatory surgical centers”

for more information.)

Dental services

In general, preventive dental services (such as cleaning,

routine dental exams, and dental x‑rays) are not covered

by Original Medicare. We cover:

Non‑routine dental care (covered services are

limited to surgery of the jaw or related structures,

setting fractures of the jaw or facial bones,

extraction of teeth to prepare the jaw for radiation

treatments of neoplastic cancer disease, or

services that would be covered when provided by a

physician)

•

$15 copay for each Medicare‑covered dental

care service.

Depression screening

We cover one screening for depression per year. The

screening must be done in a primary care setting that can

provide follow‑up treatment and/or referrals.

There is no coinsurance, copayment, or

deductible for an annual depression

screening visit.

Diabetes screening

We cover this screening (includes fasting glucose tests) if

you have any of the following risk factors: high blood

pressure (hypertension), history of abnormal cholesterol

and triglyceride levels (dyslipidemia), obesity, or a history

of high blood sugar (glucose). Tests may also be covered

if you meet other requirements, like being overweight

and having a family history of diabetes.

Based on the results of these tests, you may be eligible

for up to two diabetes screenings every 12 months.

There is no coinsurance, copayment, or

deductible for the Medicare‑covered

diabetes screening tests.

Diabetes self‑management training, diabetic

services and supplies

For all people who have diabetes (insulin and non‑insulin

users). Covered services include:

Supplies to monitor your blood glucose: Blood

glucose monitor, blood glucose test strips, lancet

devices and lancets, and glucose‑control solutions

for checking the accuracy of test strips and

monitors.

•

For people with diabetes who have severe diabetic

foot disease: One pair per calendar year of

•

$0 copay for each Medicare‑covered supply

to monitor blood glucose.

$0 copay for each pair of Medicare‑covered

diabetic shoes and inserts.

$0 copay for Medicare‑covered diabetes

self‑management training.

Aetna Medicare Plan (PPO) 2023 Schedule of Cost Sharing

Services that are covered for you

What you must pay when you get these

services

therapeutic custom‑molded shoes (including

inserts provided with such shoes) and two

additional pairs of inserts, or one pair of depth

shoes and three pairs of inserts (not including the

non‑customized removable inserts provided with

such shoes). Coverage includes fitting.

Diabetes self‑management training is covered

under certain conditions.

•

Durable medical equipment (DME) and related

supplies

(For a definition of “durable medical equipment,” see

Chapter 10 of the Evidence of Coverage.)

Covered items include, but are not limited to:

wheelchairs, crutches, powered mattress systems,

diabetic supplies, hospital beds ordered by a provider for

use in the home, IV infusion pumps, speech generating

devices, oxygen equipment, nebulizers, and walkers.

We cover all medically necessary DME covered by

Original Medicare. If our supplier in your area does not

carry a particular brand or manufacturer, you may ask

them if they can special order it for you. The most recent

list of suppliers is available on our website at:

CONY.AetnaMedicare.com.

$0 copay for each Medicare‑covered

durable medical equipment item.

Emergency care

Emergency care refers to services that are:

Furnished by a provider qualified to furnish

emergency services, and

•

Needed to evaluate or stabilize an emergency

medical condition.

•

A medical emergency is when you, or any other prudent

layperson with an average knowledge of health and

medicine, believe that you have medical symptoms that

require immediate medical attention to prevent loss of

life, loss of a limb, or loss of function of a limb. The

medical symptoms may be an illness, injury, severe pain,

or a medical condition that is quickly getting worse.

Cost sharing for necessary emergency services furnished

out‑of‑network is the same as for such services furnished

in‑network.

$50 copay for each emergency room visit.

Cost‑sharing is waived if you are

immediately admitted to the hospital.

Aetna Medicare Plan (PPO) 2023 Schedule of Cost Sharing

Services that are covered for you

What you must pay when you get these

services

This coverage is available worldwide (i.e., outside of the

United States).

Fitness program (physical fitness)

You are covered for a basic membership to any

SilverSneakers

participating fitness facility.

At‑home fitness kits and online classes are also available

if you do not reside near a participating club or prefer to

exercise at home. You may order one fitness kit per year

through SilverSneakers.

You will also have access to online enrichment classes to

support your health and wellness, as well as your mental

fitness. Health and wellness classes include, but are not

limited to: cooking, food & nutrition, and mindfulness.

Mental fitness classes include, but are not limited to: new

skills, organization, self help, and staying connected.

These classes can be accessed online by visiting

SilverSneakers.com.

To get started, you will need your SilverSneakers ID

number. Please visit SilverSneakers.com or call

SilverSneakers at 1‑888‑423‑4632 (TTY/TDD: 711) to

obtain this ID number. Then, bring this ID number with

you when you visit a participating fitness facility.

Information about participating facilities can be found by

using the SilverSneakers website or by calling

SilverSneakers.

$0 copay for health club

membership/fitness classes.

Health and wellness education programs

24‑Hour Nurse Line: Talk to a registered nurse 24

hours a day, 7 days a week. Please call

1‑855‑493‑7019 (For TTY/TDD assistance, please

dial 711.)

•

Health education: Members are eligible to receive

the health education supplemental benefit to

support a healthier lifestyle. This benefit gives

members the opportunity to interact as a group,

one‑on‑one, or virtually, with a certified health

educator or other qualified health professional.

Members may receive educational supplies such as

books and pamphlets to augment their interactive

sessions. In addition, members will be encouraged

to adopt healthy habits and build skills to enhance

self‑care capabilities.

•

There is no coinsurance, copayment, or

deductible for the 24‑Hour Nurse Line

benefit.

Health education is included in your plan.

Aetna Medicare Plan (PPO) 2023 Schedule of Cost Sharing

Services that are covered for you

What you must pay when you get these

services

Healthy Rewards

The Aetna Healthy Rewards program is a highly

personalized incentive and rewards program. Plan

members can earn rewards in the form of merchandise

gift cards by completing specific health and wellness

activities within the plan year. Coinsurance, copayment,

or deductible may apply to the medical service

completed in order to earn the reward. There is no

out‑of‑pocket cost to the member to redeem the reward

once the required activity is complete.

Included in your plan.

Hearing services

Diagnostic hearing and balance evaluations performed

by your provider to determine if you need medical

treatment are covered as outpatient care when furnished

by a physician, audiologist, or other qualified provider.

In addition to Medicare‑covered benefits, we also offer:

Routine hearing exams: one every twelve months•

$15 copay for each Medicare‑covered

hearing exam.

$0 copay for each non‑Medicare covered

hearing exam.

Hearing services ‑ Hearing aids

This is a reimbursement benefit towards the cost of

hearing aids. You may see any licensed hearing provider

in the U.S. You pay the provider for services and submit

an itemized billing statement showing proof of payment

to our plan. You must submit your documentation within

365 days from the date of service to be eligible for

reimbursement. If approved, it can take up to 45 days for

you to receive payment. If your request is incomplete,

such as no itemization of services, or there is missing

information, you will be notified by mail. You will then

have to supply the missing information, which will delay

the processing time.

Notes:

If you use a non‑licensed provider you will not

receive reimbursement.

•

You are responsible for any charges above the

reimbursement amount.

•

* Amounts you pay for hearing aids do not apply to your

Out‑of‑Pocket Maximum.

Our plan will reimburse you up to $500 once

every 12 months towards the cost of hearing

aids.

HIV screening

For people who ask for an HIV screening test or who are

at increased risk for HIV infection, we cover:

There is no coinsurance, copayment, or

deductible for members eligible for

Medicare‑covered preventive HIV

screening.

Aetna Medicare Plan (PPO) 2023 Schedule of Cost Sharing

Services that are covered for you

What you must pay when you get these

services

One screening exam every 12 months•

For women who are pregnant, we cover:

Up to three screening exams during a pregnancy•

Home health agency care

Prior to receiving home health services, a doctor must

certify that you need home health services and will order

home health services to be provided by a home health

agency. You must be homebound, which means leaving

home is a major effort.

Covered services include, but are not limited to:

Part‑time or intermittent skilled nursing and home

health aide services (To be covered under the

home health care benefit, your skilled nursing and

home health aide services combined must total

fewer than 8 hours per day and 35 hours per week.)

•

Physical therapy, occupational therapy, and speech

therapy

•

Medical and social services•

Medical equipment and supplies•

Prior authorization rules may apply for network

services. Your network provider is responsible for

requesting prior authorization. Our plan recommends

pre‑authorization of the service when provided by an

out‑of‑network provider.

$0 copay for each Medicare‑covered home

health visit.

$0 copay for each Medicare‑covered

durable medical equipment item.

Home infusion therapy

Home infusion therapy involves the intravenous or

subcutaneous administration of drugs or biologicals to an

individual at home. The components needed to perform

home infusion include the drug (for example, antivirals,

immune globulin), equipment (for example, a pump), and

supplies (for example, tubing and catheters).

Prior to receiving home infusion services, they must be

ordered by a doctor and included in your care plan.

Covered services include, but are not limited to:

Professional services, including nursing services, •

You will pay the cost‑sharing that applies to

primary care physician services, specialist

physician services (including certified home

infusion providers), or home health services

depending on where you received

administration or monitoring services.

(See “Physician/Practitioner Services,

Including Doctor's Office Visits” or “Home

Health Agency Care” for any applicable

cost‑sharing.)

Please note that home infusion drugs,

pumps, and devices provided during a home

Aetna Medicare Plan (PPO) 2023 Schedule of Cost Sharing

Services that are covered for you

What you must pay when you get these

services

furnished in accordance with the plan of care

Patient training and education not otherwise

covered under the durable medical equipment

benefit

•

Remote monitoring•

Monitoring services for the provision of home

infusion therapy and home infusion drugs furnished

by a qualified home infusion therapy supplier

•

infusion therapy visit are covered separately

under your “Durable medical equipment

(DME) and related supplies” benefit.

Hospice care

You are eligible for the hospice benefit when your doctor

and the hospice medical director have given you a

terminal prognosis certifying that you’re terminally ill and

have 6 months or less to live if your illness runs its normal

course. You may receive care from any

Medicare‑certified hospice program. Your plan is

obligated to help you find Medicare‑certified hospice

programs in the plan’s service area, including those the

MA organization owns, controls, or has a financial interest

in. Your hospice doctor can be a network provider or an

out‑of‑network provider.

Covered services include:

Drugs for symptom control and pain relief•

Short‑term respite care•

Home care•

When you are admitted to a hospice you have the right to

remain in your plan; if you choose to remain in your plan

you must continue to pay plan premiums.

For hospice services and for services that are covered by

Medicare Part A or B and are related to your terminal

prognosis: Original Medicare (rather than our plan) will

pay for your hospice services and any Part A and Part B

services related to your terminal prognosis. While you are

in the hospice program, your hospice provider will bill

Original Medicare for the services that Original Medicare

pays for. You will be billed Original Medicare cost sharing.

For services that are covered by Medicare Part A or B and

are not related to your terminal prognosis: If you need

non‑emergency, non‑urgently needed services that are

covered under Medicare Part A or B and that are not

related to your terminal prognosis, you pay your plan

cost‑sharing amount for these services and you must

When you enroll in a Medicare‑certified

hospice program, your hospice services and

your Part A and Part B services related to

your terminal prognosis are paid for by

Original Medicare, not our plan.

Hospice consultations are included as part

of inpatient hospital care. Physician service

cost‑sharing may apply for outpatient

consultations.

Aetna Medicare Plan (PPO) 2023 Schedule of Cost Sharing

Services that are covered for you

What you must pay when you get these

services

follow plan rules (such as if there is a requirement to

obtain prior authorization).

For services that are covered by Aetna Medicare Plan

(PPO) but are not covered by Medicare Part A or B: Aetna

Medicare Plan (PPO) will continue to cover plan‑covered

services that are not covered under Part A or B whether

or not they are related to your terminal prognosis. You

pay your plan cost‑sharing amount for these services.

Note:If you need non‑hospice care (care that is not

related to your terminal prognosis), you should contact us

to arrange the services.

Our plan covers hospice consultation services (one time

only) for a terminally ill person who hasn’t elected the

hospice benefit.

Immunizations

Covered Medicare Part B services include:

Pneumonia vaccine•

Flu shots, once each flu season in the fall and

winter, with additional flu shots if medically

necessary

•

Hepatitis B vaccine if you are at high or

intermediate risk of getting Hepatitis B

•

COVID‑19 vaccine•

Other vaccines if you are at risk and they meet

Medicare Part B coverage rules

•

There is no coinsurance, copayment, or

deductible for the pneumonia, influenza,

Hepatitis B, and COVID‑19 vaccines.

$0 copay for other Medicare‑covered Part B

vaccines.

You may have to pay an office visit cost

share if you get other services at the same

time that you get vaccinated.

Inpatient hospital care

Includes inpatient acute, inpatient rehabilitation,

long‑term care hospitals, and other types of inpatient

hospital services. Inpatient hospital care starts the day

you are formally admitted to the hospital with a doctor’s

order. The day before you are discharged is your last

inpatient day.

Days covered: There is no limit to the number of days

covered by our plan. Cost‑sharing is not charged on the

day of discharge.

Covered services include but are not limited to:

Semi‑private room (or a private room if medically

necessary)

•

For each inpatient hospital stay, you pay:

$0 per stay 09/01/23–12/31/23.

$300 per stay, maximum of $750 per

calendar year 01/01/24–12/31/24.

Cost‑sharing is charged for each medically

necessary covered inpatient stay.

Aetna Medicare Plan (PPO) 2023 Schedule of Cost Sharing

Services that are covered for you

What you must pay when you get these

services

Meals including special diets•

Regular nursing services•

Costs of special care units (such as intensive care

or coronary care units)

•

Drugs and medications•

Lab tests•

X‑rays and other radiology services•

Necessary surgical and medical supplies

•

Use of appliances, such as wheelchairs•

Operating and recovery room costs•

Physical, occupational, and speech language

therapy

•

Inpatient substance abuse services•

Under certain conditions, the following types of

transplants are covered: corneal, kidney,

kidney‑pancreatic, heart, liver, lung, heart/lung,

bone marrow, stem cell, and

intestinal/multivisceral. If you need a transplant, we

will arrange to have your case reviewed by a

Medicare‑approved transplant center that will

decide whether you are a candidate for a

transplant. Transplant providers may be local or

outside of the service area. If our in‑network

transplant services are outside the community

pattern of care, you may choose to go locally as

long as the local transplant providers are willing to

accept the Original Medicare rate. If our plan

provides transplant services at a location outside

the pattern of care for transplants in your

community and you choose to obtain transplants at

this distant location, we will arrange or pay for

appropriate lodging and transportation costs for

you and a companion.

•

Blood ‑ including storage and administration.

Coverage of whole blood and packed red cells

begins with the first pint of blood that you need. All

components of blood are covered beginning with

the first pint used.

•

Physician services•

Note: To be an inpatient, your provider must write an

order to admit you formally as an inpatient of the hospital.

Even if you stay in the hospital overnight, you might still

be considered an “outpatient.” If you are not sure if you

are an inpatient or an outpatient, you should ask the

Aetna Medicare Plan (PPO) 2023 Schedule of Cost Sharing

Services that are covered for you

What you must pay when you get these

services

hospital staff.

You can also find more information in a Medicare fact

sheet called “Are You a Hospital Inpatient or Outpatient?

If You Have Medicare – Ask!” This fact sheet is available

on the Web at

www.medicare.gov/sites/default/files/2021-10/11435-

Inpatient-or-Outpatient.pdfor by calling

1‑800‑MEDICARE (1‑800‑633‑4227). TTY users call

1‑877‑486‑2048. You can call these numbers for free, 24

hours a day, 7 days a week.

Prior authorization rules apply for network services.

Your network provider is responsible for requesting

prior authorization. Our plan recommends

pre‑authorization of the service when provided by an

out‑of‑network provider.

Inpatient services in a psychiatric hospital

Covered services include mental health care services

that require a hospital stay.

Days covered: There is no limit to the number of days

covered by our plan. Cost‑sharing is not charged on the

day of discharge.

Prior authorization rules apply for network services.

Your network provider is responsible for requesting

prior authorization. Our plan recommends

pre‑authorization of the service when provided by an

out‑of‑network provider.

For each inpatient stay, you pay:

$0 per stay 09/01/23–12/31/23.

$300 per stay, maximum of $750 per

calendar year 01/01/24–12/31/24.

Cost‑sharing is charged for each medically

necessary covered inpatient stay.

Inpatient stay: Covered services received in a hospital

or SNF during a non‑covered inpatient stay

If you have exhausted your skilled nursing facility benefits

or if the skilled nursing facility or inpatient stay is not

reasonable and necessary, we will not cover your

inpatient stay. However, in some cases, we will cover

certain services you receive while you are in the hospital

or the skilled nursing facility (SNF).

Covered services include, but are not limited to:

Physician services•

Diagnostic tests (like lab tests)•

X‑ray, radium, and isotope therapy including

technician materials and services

•

Surgical dressings•

$0 copay for Medicare‑covered primary

care physician (PCP) services.

$15 copay for Medicare‑covered specialist

services.

$15 copay for each Medicare‑covered

diagnostic procedure and test.

$15 copay for each Medicare‑covered lab

service.

$0 copay for certain Medicare‑covered lab

services including Hemoglobin A1c, Urine

Protein, Prothrombin (Protime), Urine

Albumin, Fecal immunochemical test (FIT),

Aetna Medicare Plan (PPO) 2023 Schedule of Cost Sharing

Services that are covered for you

What you must pay when you get these

services

Splints, casts and other devices used to reduce

fractures and dislocations

•

Prosthetics and orthotics devices (other than

dental) that replace all or part of an internal body

organ (including contiguous tissue), or all or part of

the function of a permanently inoperative or

malfunctioning internal body organ, including

replacement or repairs of such devices

•

Leg, arm, back, and neck braces; trusses; and

artificial legs, arms, and eyes including

adjustments, repairs, and replacements required

because of breakage, wear, loss, or a change in the

patient’s physical condition

•

Physical therapy, speech therapy, and occupational

therapy

•

Prior authorization rules apply for network services.

Your network provider is responsible for requesting

prior authorization. Our plan recommends

pre‑authorization of the service when provided by an

out‑of‑network provider.

Kidney Health Evaluation for members with

Diabetes (KED), and COVID‑19 testing.

$15 copay for each Medicare‑covered

diagnostic radiology and complex imaging

service.

$15 copay for each Medicare‑covered x‑ray.

$0 copay for each Medicare‑covered

therapeutic radiology service.

Your cost share for medical supplies is

based upon the provider of services.

$0 copay for continuous glucose meter

supplies.

$0 copay for each Medicare‑covered

prosthetic device.

$15 copay for each Medicare‑covered

physical or speech therapy visit.

$15 copay for each Medicare‑covered

occupational therapy visit.

Meal benefit

After discharge from an Inpatient Acute Hospital,

Inpatient Psychiatric Hospital or Skilled Nursing Facility to

your home, you may be eligible to receive up to 28

home‑delivered meals over a 14‑day period delivered to

your home. After our plan confirms that this benefit will

help support your recovery or manage your health

conditions, and is not based solely on convenience or

comfort purposes, you will be contacted by our partner,

GA Foods, to schedule delivery.

Note: Observation stays do not qualify you for this

benefit.

$0 copay for covered meals.

Medical nutrition therapy

This benefit is for people with diabetes, renal (kidney)

disease (but not on dialysis), or after a kidney transplant

when ordered by your doctor.

We cover 3 hours of one‑on‑one counseling services

during your first year that you receive medical nutrition

therapy services under Medicare (this includes our plan,

There is no coinsurance, copayment, or

deductible for members eligible for

Medicare‑covered medical nutrition therapy

services.

Aetna Medicare Plan (PPO) 2023 Schedule of Cost Sharing

Services that are covered for you

What you must pay when you get these

services

any other Medicare Advantage plan, or Original

Medicare), and 2 hours each year after that. If your

condition, treatment, or diagnosis changes, you may be

able to receive more hours of treatment with a

physician’s order. A physician must prescribe these

services and renew their order yearly if your treatment is

needed into the next calendar year.

Medicare Diabetes Prevention Program (MDPP)

MDPP services will be covered for eligible Medicare

beneficiaries under all Medicare health plans.

MDPP is a structured health behavior change

intervention that provides practical training in long‑term

dietary change, increased physical activity, and

problem‑solving strategies for overcoming challenges to

sustaining weight loss and a healthy lifestyle.

There is no coinsurance, copayment, or

deductible for the MDPP benefit.

Medicare Part B prescription drugs

These drugs are covered under Part B of Original

Medicare. Members of our plan receive coverage for

these drugs through our plan.

Covered drugs include:

Drugs that usually aren’t self‑administered by the

patient and are injected or infused while you are

getting physician, hospital outpatient, or

ambulatory surgical center services

•

Drugs you take using durable medical equipment

(such as nebulizers) that were authorized by the

plan

•

Clotting factors you give yourself by injection if you

have hemophilia

•

Immunosuppressive drugs, if you were enrolled in

Medicare Part A at the time of the organ transplant

•

Injectable osteoporosis drugs, if you are

homebound, have a bone fracture that a doctor

certifies was related to post‑menopausal

osteoporosis, and cannot self‑administer the drug

•

Antigens•

Certain oral anti‑cancer drugs and anti‑nausea

drugs

•

Certain drugs for home dialysis, including heparin,

the antidote for heparin when medically necessary,

topical anesthetics, and erythropoiesis‑stimulating

agents (such as Epogen®, Procrit®, Epoetin Alfa,

Aranesp®, or Darbepoetin Alfa)

•

$0 copay per prescription or refill.

$0 copay for each chemotherapy or infusion

therapy Part B drug.

$0 copay for the administration of the

chemotherapy drug as well as for infusion

therapy.

$0 copay for each allergy shot. You may

have to pay an office visit cost share if you

get other services at the same time that you

get the allergy shot.

Part B drugs may be subject to Step Therapy

requirements.

Aetna Medicare Plan (PPO) 2023 Schedule of Cost Sharing

Services that are covered for you

What you must pay when you get these

services

Intravenous Immune Globulin for the home

treatment of primary immune deficiency diseases

•

Allergy shots•

The following link will take you to a list of Part B Drugs

that may be subject to Step Therapy:

Aetna.com/partb-step.

We also cover some vaccines under our Part B

prescription drug benefit.



Prior authorization rules may apply for network

services. Your network provider is responsible for

requesting prior authorization. Our plan recommends

pre‑authorization of the service when provided by an

out‑of‑network provider.

Obesity screening and therapy to promote

sustained weight loss

If you have a body mass index of 30 or more, we cover

intensive counseling to help you lose weight. This

counseling is covered if you get it in a primary care

setting, where it can be coordinated with your

comprehensive prevention plan. Talk to your primary

care doctor or practitioner to find out more.

There is no coinsurance, copayment, or

deductible for preventive obesity screening

and therapy.

Opioid treatment program services

Members of our plan with opioid use disorder (OUD) can

receive coverage of services to treat OUD through an

Opioid Treatment Program (OTP) which includes the

following services:

U.S. Food and Drug Administration (FDA)‑approved

opioid agonist and antagonist medication‑assisted

treatment (MAT) medications

•

Dispensing and administration of MAT medications

(if applicable)

•

Substance use counseling•

Individual and group therapy•

Toxicology testing•

Intake activities•

Periodic assessments•

$15 copay for each Medicare‑covered opioid

use disorder treatment service.

Outpatient diagnostic tests and therapeutic services

and supplies

Covered services include, but are not limited to:

Your cost share is based on:

the tests, services, and supplies you •

Aetna Medicare Plan (PPO) 2023 Schedule of Cost Sharing

Services that are covered for you

What you must pay when you get these

services

X‑rays•

Radiation (radium and isotope) therapy including

technician materials and supplies

•

Surgical supplies, such as dressings•

Diagnostic radiology and complex imaging such as:

MRI, MRA, PET scan

•

Splints, casts and other devices used to reduce

fractures and dislocations

•

Laboratory tests•

Blood ‑ including storage and administration.

Coverage of whole blood and packed red cells

begins with the first pint of blood that you need. All

components of blood are covered beginning with

the first pint used.

•

Other outpatient diagnostic tests•

receive

the provider of the tests, services, and

supplies

•

the setting where the tests, services, and

supplies are performed

•

$15 copay for each Medicare‑covered x‑ray.

$15 copay for each Medicare‑covered

diagnostic radiology and complex imaging

service.

$15 copay for each Medicare‑covered lab

service.

$0 copay for certain Medicare‑covered lab

services including Hemoglobin A1c, Urine

Protein, Prothrombin (Protime), Urine

Albumin, Fecal immunochemical test (FIT),

Kidney Health Evaluation for members with

Diabetes (KED), and COVID‑19 testing.

$0 copay for Medicare‑covered blood

services.

$15 copay for each Medicare‑covered

diagnostic procedure and test.

$15 copay for each Medicare‑covered CT

scan.

$15 copay for each Medicare‑covered

diagnostic radiology service other than CT

scan.

$0 copay for each Medicare‑covered retinal

fundus service, Spirometry, and Peripheral

Arterial Disease (PAD).

$0 copay for each Medicare‑covered

therapeutic radiology service.

Your cost share for medical supplies is

based upon the provider of services.

$0 copay for continuous glucose meter

supplies.

Aetna Medicare Plan (PPO) 2023 Schedule of Cost Sharing

Services that are covered for you

What you must pay when you get these

services

Outpatient hospital observation

Observation services are hospital outpatient services

given to determine if you need to be admitted as an

inpatient or can be discharged.

For outpatient hospital observation services to be

covered, they must meet the Medicare criteria and be

considered reasonable and necessary. Observation

services are covered only when provided by the order of

a physician or another individual authorized by state

licensure law and hospital staff bylaws to admit patients

to the hospital or order outpatient tests.

Note: Unless the provider has written an order to admit

you as an inpatient to the hospital, you are an outpatient

and pay the cost‑sharing amounts for outpatient hospital

services. Even if you stay in the hospital overnight, you

might still be considered an “outpatient.” If you are not

sure if you are an outpatient, you should ask the hospital

staff.

You can also find more information in a Medicare fact

sheet called “Are You a Hospital Inpatient or Outpatient?

If You Have Medicare – Ask!” This fact sheet is available

on the Web at

www.medicare.gov/sites/default/files/2021-10/11435-

Inpatient-or-Outpatient.pdf or by calling

1‑800‑MEDICARE (1‑800‑633‑4227). TTY users call

1‑877‑486‑2048. You can call these numbers for free, 24

hours a day, 7 days a week.

Your cost share for Observation Care is

based upon the services you receive.

Outpatient hospital services

We cover medically‑necessary services you get in the

outpatient department of a hospital for diagnosis or

treatment of an illness or injury.

Covered services include, but are not limited to:

Services in an emergency department or outpatient

clinic, such as observation services or outpatient

surgery

•

Laboratory and diagnostic tests billed by the

hospital

•

Mental health care, including care in a

partial‑hospitalization program, if a doctor certifies

that inpatient treatment would be required without

•

X‑rays and other radiology services billed by the •

$0 copay per facility visit.

Your cost share is based on:

the tests, services, and supplies you

receive

•

the provider of the tests, services, and

supplies

•

the setting where the tests, services, and

supplies are performed

•

$50 copay for each emergency room visit.

Cost‑sharing is waived if you are

immediately admitted to the hospital.

$15 copay for each Medicare‑covered

diagnostic procedure and test.

Aetna Medicare Plan (PPO) 2023 Schedule of Cost Sharing

Services that are covered for you

What you must pay when you get these

services

$15 copay for each Medicare‑covered lab

service.

$0 copay for certain Medicare‑covered lab

services including Hemoglobin A1c, Urine

Protein, Prothrombin (Protime), Urine

Albumin, Fecal immunochemical test (FIT),

Kidney Health Evaluation for members with

Diabetes (KED), and COVID‑19 testing.

$15 copay for each Medicare‑covered

diagnostic radiology and complex imaging

service.

$15 copay for each Medicare‑covered x‑ray.

$0 copay for each Medicare‑covered

therapeutic radiology service.

$15 copay for each Medicare‑covered

outpatient mental health service provided by

a psychiatrist (individual session).

$15 copay for each Medicare‑covered

outpatient mental health service provided by

a psychiatrist (group session).

$15 copay for each Medicare‑covered

outpatient mental health service provided by

a mental health professional other than a

psychiatrist (individual session).

$15 copay for each Medicare‑covered

outpatient mental health service provided by

a mental health professional other than a

psychiatrist (group session).

$15 copay for each Medicare‑covered partial

hospitalization visit.

Your cost share for medical supplies is

based upon the provider of services.

$0 copay for continuous glucose meter

supplies.

$0 copay per prescription or refill for certain

drugs and biologicals that you can’t give

hospital

Medical supplies such as splints and casts•

Certain drugs and biologicals that you can’t give

yourself

•

Note: Unless the provider has written an order to admit

you as an inpatient to the hospital, you are an outpatient

and pay the cost‑sharing amounts for outpatient hospital

services. Even if you stay in the hospital overnight, you

might still be considered an “outpatient.” If you are not

sure if you are an outpatient, you should ask the hospital

staff.

You can also find more information in a Medicare fact

sheet called “Are You a Hospital Inpatient or Outpatient?

If You Have Medicare – Ask!” This fact sheet is available

on the Web at

www.medicare.gov/sites/default/files/2021-10/11435-

Inpatient-or-Outpatient.pdf or by calling

1‑800‑MEDICARE (1‑800‑633‑4227). TTY users call

1‑877‑486‑2048. You can call these numbers for free, 24

hours a day, 7 days a week.

Aetna Medicare Plan (PPO) 2023 Schedule of Cost Sharing

Services that are covered for you

What you must pay when you get these

services

yourself.

Outpatient mental health care

Covered services include:

Mental health services provided by a state‑licensed

psychiatrist or doctor, clinical psychologist, clinical social

worker, clinical nurse specialist, nurse practitioner,

physician assistant, or other Medicare‑qualified mental

health care professional as allowed under applicable

state laws.

We also cover some telehealth visits with psychiatric and

mental health professionals. See

“Physician/Practitioner services, including doctor’s

office visits” for information about telehealth outpatient

mental health care.

$15 copay for each Medicare‑covered

outpatient mental health service provided by

a psychiatrist (individual session).

$15 copay for each Medicare‑covered

outpatient mental health service provided by

a psychiatrist (group session).

$15 copay for each Medicare‑covered

outpatient mental health service provided by

a mental health professional other than a

psychiatrist (individual session).

$15 copay for each Medicare‑covered

outpatient mental health service provided by

a mental health professional other than a

psychiatrist (group session).

Outpatient rehabilitation services

Covered services include: physical therapy, occupational

therapy, and speech language therapy.



Outpatient rehabilitation services are provided in various

outpatient settings, such as hospital outpatient

departments, independent therapist offices, and

Comprehensive Outpatient Rehabilitation Facilities

(CORFs).

$15 copay for each Medicare‑covered

physical or speech therapy visit.

$15 copay for each Medicare‑covered

occupational therapy visit.

Outpatient substance abuse services

Our coverage is the same as Original Medicare, which is

coverage for services that are provided in the outpatient

department of a hospital to patients who, for example,

have been discharged from an inpatient stay for the

treatment of drug substance abuse or who require

treatment but do not require the availability and intensity

of services found only in the inpatient hospital setting.

The coverage available for these services is subject to the

same rules generally applicable to the coverage of

outpatient hospital services.

Covered services include:

Assessment, evaluation, and treatment for

substance use related disorders by a

Medicare‑eligible provider to quickly determine the

•

$15 copay for each Medicare‑covered

individual outpatient substance abuse

session.

$15 copay for each Medicare‑covered group

outpatient substance abuse session.

Aetna Medicare Plan (PPO) 2023 Schedule of Cost Sharing

Services that are covered for you

What you must pay when you get these

services

severity of substance use and identify the

appropriate level of treatment

Brief interventions or advice focusing on increasing

insight and awareness regarding substance use

and motivation toward behavioral change

•

Outpatient surgery, including services provided at

hospital outpatient facilities and ambulatory surgical

centers

Note: If you are having surgery in a hospital facility, you

should check with your provider about whether you will

be an inpatient or outpatient. Unless the provider writes

an order to admit you as an inpatient to the hospital, you

are an outpatient and pay the cost‑sharing amounts for

outpatient surgery. Even if you stay in the hospital

overnight, you might still be considered an “outpatient.”

Your cost share is based on:

the tests, services, and supplies you

receive

•

the provider of the tests, services, and

supplies

•

the setting where the tests, services, and

supplies are performed

•

$0 copay for each Medicare‑covered

outpatient surgery at a hospital outpatient

facility.

$0 copay for each Medicare‑covered

outpatient surgery at an ambulatory surgical

center.

Over‑the‑counter (OTC) items

This plan comes with a $30 quarterly allowance for

over‑the‑counter (OTC) medications and supplies. For a

complete list of covered items, please refer to the OTC

catalog.

You may place up to three orders each quarter and are

limited to up to nine (9) like items per quarter (every three

months), with the exception of blood pressure monitors,

which are limited to one per year. Orders cannot exceed

your quarterly allowance.

Any unused allowance will not be rolled over into the

following quarter.

Items may be ordered over the phone at 1‑833‑331‑1573

(TTY: 711) Monday‑Friday 9 am‑8 pm local time (except

Hawaii) or online at cvs.com/otchs/myorder to be

shipped to your home. You can place an order online 24

hours a day, 7 days a week (24/7). Ordered items are for

enrollee only.

Notes:

There is no coinsurance, copayment, or

deductible for covered OTC items

This benefit includes certain nicotine

replacement therapies.

Aetna Medicare Plan (PPO) 2023 Schedule of Cost Sharing

Services that are covered for you

What you must pay when you get these

services

You cannot pay out‑of‑pocket for the difference

above your allowance.

•

The OTC limits apply to in‑store/retail transactions,

where available.

•

Reimbursements are not allowed for this benefit.

Items purchased outside of the benefit are not

covered or reimbursable. Members cannot mail in

their OTC order to Member Services.

•

Quantity limits may apply to select items.•

Partial hospitalization services

“Partial hospitalization” is a structured program of active

psychiatric treatment provided as a hospital outpatient

service or by a community mental health center, that is

more intense than the care received in your doctor’s or

therapist’s office and is an alternative to inpatient

hospitalization.

$15 copay for each Medicare‑covered partial

hospitalization visit.

Personal emergency response system

We cover a personal emergency response system to

provide you with 24/7 access to help in the event of an

emergency. This benefit includes the equipment

(in‑home or mobile with GPS), shipping, fulfillment,

monitoring and customer service. You may call

LifeStation at this toll free number: 1‑855‑798‑9948 to

There is no coinsurance, copayment, or

deductible for the Personal Emergency

Response System service.

Physician/Practitioner services, including doctor’s

office visits

Covered services include:

Medically‑necessary medical care or surgery

services furnished in a physician’s office, certified

ambulatory surgical center, hospital outpatient

department, or any other location

•

Consultation, diagnosis, and treatment by a

specialist

•

Basic hearing and balance exams performed by

your specialist, if your doctor orders it to see if you

need medical treatment

•

Certain telehealth services, including:

Primary care physician services

○

Physician specialist services

○

Mental health services (individual sessions)

○

Mental health services (group sessions)

○

Psychiatric services (individual sessions)

○

•

Your cost share is based on:

the tests, services, and supplies you

receive

•

the provider of the tests, services, and

supplies

•

the setting where the tests, services, and

supplies are performed

•

$0 copay for Medicare‑covered primary

care physician (PCP) services (including

telehealth services and urgently needed

services).

$15 copay for Medicare‑covered physician

specialist services (including surgery second

opinion, telehealth services, home infusion

professional services, and urgently needed

services).

$15 copay for each Medicare‑covered

Aetna Medicare Plan (PPO) 2023 Schedule of Cost Sharing

Services that are covered for you

What you must pay when you get these

services

Psychiatric services (group sessions)

○

Urgently needed services

○

Occupational therapy services

○

Physical and speech therapy services

○

Opioid treatment services

○

Outpatient substance abuse services (individual

sessions)

○

Outpatient substance abuse services (group

sessions)

○

Kidney disease education services

○

Diabetes self‑management services

○

Your plan also offers MDLive for behavioral

telehealth services. You can schedule a telehealth

visit through MDLive, which provides virtual access

to board‑certified psychiatrists and licensed

therapists in all 50 states. These telehealth visits

can be scheduled through the MDLive call center,

web portal, or mobile app. The call center is

available 24/7, 365 days per year. Visits can be

scheduled or on demand. Call 1‑888‑865‑0729

(available 24/7), TTY: 1‑800‑770‑5531, visit

mdlive.com/aetnamedicarebh, or access the

MDLive mobile app. Due to provider licensing,

members must be located within the United States

and Puerto Rico when using MDLive services.

•

This coverage is in addition to the telehealth

services described below. For more details on your

additional telehealth coverage, please review the

Aetna Medicare Telehealth Coverage Policy at

AetnaMedicare.com/Telehealth.

You have the option of getting these services

through an in‑person visit or by telehealth. If you

choose to get one of these services by

telehealth, you must use a provider who offers

the service by telehealth. Not all providers offer

telehealth services.

○

You should contact your doctor for information

on what telehealth services they offer and how

to schedule a telehealth visit. Depending on

location, members may also have the option to

schedule a telehealth visit 24 hours a day, 7 days

a week via Teladoc, MinuteClinic Video Visit, or

other provider that offers telehealth services

covered under your plan. Members can access

Teladoc at Teladoc.com/Aetna or by calling

1‑855‑TELADOC (1‑855‑835‑2362) (TTY: 711),

○

•

hearing exam.

Certain additional telehealth services,

including those for:

$0 copay for each primary care

physician service

•

$15 copay for each physician specialist

service

•

$15 copay for each mental health

service (individual sessions)

•

$15 copay for each mental health

service (group sessions)

•

$15 copay for each psychiatric service

(individual sessions)

•

$15 copay for each psychiatric service

(group sessions)

•

$15 copay for each urgently needed

service

•

$15 copay for each occupational

therapy visit

•

$15 copay for each physical or speech

therapy visit

•

$15 copay for each opioid treatment

program service

•

$15 copay for each individual

outpatient substance abuse service

•

$15 copay for each group outpatient

substance abuse service

•

$0 copay for each kidney disease

education service

•

$0 copay for each diabetes

self‑management training service

•

$0 copay for each Teladoc telehealth

service.

Aetna Medicare Plan (PPO) 2023 Schedule of Cost Sharing

Services that are covered for you

What you must pay when you get these

services

available 24/7. Note: Teladoc is not currently

available outside of the United States and its

territories (Guam, Puerto Rico, and the U.S.

Virgin Islands). You can find out if MinuteClinic

Video Visits are available in your area at

CVS.com/MinuteClinic/virtual-care/videovisit.

Some telehealth services including consultation,

diagnosis, and treatment by a physician or

practitioner, for patients in certain rural areas or

other places approved by Medicare

•

Telehealth services for monthly end‑stage renal

disease‑related visits for home dialysis members in

a hospital‑based or critical access hospital‑based

renal dialysis center, renal dialysis facility, or the

member’s home

•

Telehealth services to diagnose, evaluate, or treat

symptoms of a stroke regardless of your location

•

Telehealth services for members with a substance

use disorder or co‑occurring mental health

disorder, regardless of their location

•

Telehealth services for diagnosis, evaluation, and

treatment of mental health disorders if:

•

You have an in‑person visit within 6 months prior

to your first telehealth visit

•

You have an in‑person visit every 12 months

while receiving these telehealth services

•

Exceptions can be made to the above for certain

circumstances

•

Telehealth services for mental health visits

provided by Rural Health Clinics and Federally

Qualified Health Centers

•

Virtual check‑ins (for example, by phone or video

chat) with your doctor for 5‑10 minutes if:

You’re not a new patient and

○

The check‑in isn’t related to an office visit in the

past 7 days and

○

The check‑in doesn’t lead to an office visit within

24 hours or the soonest available appointment

○

•

Evaluation of video and/or images you send to your

doctor, and interpretation and follow‑up by your

doctor within 24 hours if:

You’re not a new patient and

○

The evaluation isn’t related to an office visit in

the past 7 days and

○

The evaluation doesn’t lead to an office visit

within 24 hours or the soonest available

○

•

$0 copay for each mental health telehealth

service provided by MDLive.

$15 copay for each Medicare‑covered dental

care service.

$0 copay for Medicare‑covered allergy

testing.

$0 copay for nationally contracted walk‑in

clinics.

Aetna Medicare Plan (PPO) 2023 Schedule of Cost Sharing

Services that are covered for you

What you must pay when you get these

services

appointment

Consultation your doctor has with other doctors by

phone, internet, or electronic health record

•

Second opinion by another network provider prior

to surgery

•

Non‑routine dental care (covered services are

limited to surgery of the jaw or related structures,

setting fractures of the jaw or facial bones,

extraction of teeth to prepare the jaw for radiation

treatments of neoplastic cancer disease, or

services that would be covered when provided by a

physician)

•

Allergy testing•

Podiatry services

Covered services include:

Diagnosis and the medical or surgical treatment of

injuries and diseases of the feet (such as hammer

toe or heel spurs)

•

Routine foot care for members with certain medical

conditions affecting the lower limbs

•

$15 copay for each Medicare‑covered

podiatry service.

Podiatry services (additional)

The reduction of nails, including mycotic nails, and the

removal of corns and calluses.

In addition to Medicare‑covered benefits, we also offer:

Additional non‑Medicare covered podiatry

services: unlimited visits per year

•

$15 copay for each non‑Medicare covered

podiatry service.

Private duty nursing

Private duty nursing is continuous, skilled, one‑on‑one

nursing care provided in the home by registered nurses

(RNs) or licensed practical nurses (LPNs). You must meet

plan criteria, including medical necessity, and use of

appropriately licensed providers. The private nursing

must be ordered by your physician and part of a plan of

care that is routinely updated. Private duty nursing is

different from care given by people who are not nurses

(often called “sitters”) who provide non‑skilled care

(bathing and other hygiene assistance, assistance with

eating, etc.) and companionship to patients.

Maximum allowance: $5,000

20% of the total cost for private duty

nursing.

Aetna Medicare Plan (PPO) 2023 Schedule of Cost Sharing

Services that are covered for you

What you must pay when you get these

services

Maximum allowance frequency: every year

Prostate cancer screening exams

For men age 50 and older, covered services include the

following once every 12 months:

Digital rectal exam•

Prostate Specific Antigen (PSA) test•

There is no coinsurance, copayment, or

deductible for an annual PSA test.

$0 copay for each Medicare covered digital

rectal exam.

Prosthetic devices and related supplies

Devices (other than dental) that replace all or part of a

body part or function. These include but are not limited

to: colostomy bags and supplies directly related to

colostomy care, pacemakers, braces, prosthetic shoes,

artificial limbs, and breast prostheses (including a

surgical brassiere after a mastectomy). Includes certain

supplies related to prosthetic devices, and repair and/or

replacement of prosthetic devices. Also includes some

coverage following cataract removal or cataract surgery

– see “Vision Care” later in this section for more detail.

$0 copay for each Medicare‑covered

prosthetic device.

Pulmonary rehabilitation services

Comprehensive programs of pulmonary rehabilitation are

covered for members who have moderate to very severe

chronic obstructive pulmonary disease (COPD) and an

order for pulmonary rehabilitation from the doctor

treating the chronic respiratory disease.

$0 copay for each Medicare‑covered

pulmonary rehabilitation service.

Resources for Living

Resources for Living consultants provide research

services for members on such topics as caregiver

support, household services, eldercare services,

activities, and volunteer opportunities. The purpose of the

program is to assist members in locating local community

services and to provide resource information for a wide

variety of eldercare and life‑related issues. Call

Resources for Livingat1‑866‑370‑4842.

There is no coinsurance, copayment, or

deductible forResources for Living.

Screening and counseling to reduce alcohol misuse

We cover one alcohol misuse screening for adults with

Medicare (including pregnant women) who misuse

alcohol but aren’t alcohol dependent.

If you screen positive for alcohol misuse, you can get up

to 4 brief face‑to‑face counseling sessions per year (if

you’re competent and alert during counseling) provided

There is no coinsurance, copayment, or

deductible for the Medicare‑covered

screening and counseling to reduce alcohol

misuse preventive benefit.

Aetna Medicare Plan (PPO) 2023 Schedule of Cost Sharing

Services that are covered for you

What you must pay when you get these

services

by a qualified primary care doctor or practitioner in a

primary care setting.

Screening for lung cancer with low dose computed

tomography (LDCT)

For qualified individuals, a LDCT is covered every 12

months.



Eligible members are: people aged 50 – 77 years who

have no signs or symptoms of lung cancer, but who have

a history of tobacco smoking of at least 20 pack‑years

and who currently smoke or have quit smoking within the

last 15 years, who receive a written order for LDCT during

a lung cancer screening counseling and shared

decision‑making visit that meets the Medicare criteria for

such visits and be furnished by a physician or qualified

non‑physician practitioner.



For LDCT lung cancer screenings after the initial LDCT

screening: the member must receive a written order for

LDCT lung cancer screening, which may be furnished

during any appropriate visit with a physician or qualified

non‑physician practitioner. If a physician or qualified

non‑physician practitioner elects to provide a lung cancer

screening counseling and shared decision making visit

for subsequent lung cancer screenings with LDCT, the

visit must meet the Medicare criteria for such visits.

There is no coinsurance, copayment, or

deductible for the Medicare‑covered

counseling and shared decision making visit

or for the LDCT.

Screening for sexually transmitted infections (STIs)

and counseling to prevent STIs

We cover sexually transmitted infection (STI) screenings

for chlamydia, gonorrhea, syphilis, and Hepatitis B. These

screenings are covered for pregnant women and for

certain people who are at increased risk for an STI when

the tests are ordered by a primary care provider. We

cover these tests once every 12 months or at certain

times during pregnancy.



We also cover up to 2 individual 20 to 30 minute,

face‑to‑face high‑intensity behavioral counseling

sessions each year for sexually active adults at increased

risk for STIs. We will only cover these counseling sessions

as a preventive service if they are provided by a primary

care provider and take place in a primary care setting,

such as a doctor’s office.

There is no coinsurance, copayment, or

deductible for the Medicare‑covered

screening for STIs and counseling for STIs

preventive benefit.

Services to treat kidney disease

Covered services include:

$0 copay for self‑dialysis training.

$0 copay for each Medicare‑covered kidney

Aetna Medicare Plan (PPO) 2023 Schedule of Cost Sharing

Services that are covered for you

What you must pay when you get these

services

Kidney disease education services to teach kidney

care and help members make informed decisions

about their care. For members with stage IV

chronic kidney disease when referred by their

doctor, we cover up to six sessions of kidney

disease education services per lifetime

•

Outpatient dialysis treatments (including dialysis

treatments when temporarily out of the service

area, as explained in Chapter 3 of the Evidence of

Coverage, or when your provider for this service is

temporarily unavailable or inaccessible)

•

Inpatient dialysis treatments (if you are admitted as

an inpatient to a hospital for special care)

•

Self‑dialysis training (includes training for you and

anyone helping you with your home dialysis

treatments)

•

Home dialysis equipment and supplies•

Certain home support services (such as, when

necessary, visits by trained dialysis workers to

check on your home dialysis, to help in

emergencies, and check your dialysis equipment

and water supply)

•

Certain drugs for dialysis are covered under your

Medicare Part B drug benefit. For information about

coverage for Part B Drugs, please go to the section,

“Medicare Part B prescription drugs.”

disease education session.



$0 copay for in‑ and out‑of‑area outpatient

dialysis.



See “Inpatient hospital care” for more

information on inpatient services.



$0 copay for home dialysis equipment and

supplies.



$0 copay for Medicare‑covered home

support services.

Skilled nursing facility (SNF) care

(For a definition of “skilled nursing facility care,” see the

final chapter (“Definitions of important words”) of the

Evidence of Coverage. Skilled nursing facilities are

sometimes called “SNFs.”)



Days covered: up to 100 days per benefit period. A prior

hospital stay is not required.



Covered services include but are not limited to:

Semiprivate room (or a private room if medically

necessary)

•

Meals, including special diets•

Skilled nursing services•

Physical therapy, occupational therapy, and speech

therapy

•

Drugs administered to you as part of your plan of

care (This includes substances that are naturally

•

$0 per day, days 1‑100 for each

Medicare‑covered SNF stay.

A benefit period begins the day you go into a

hospital or skilled nursing facility. The benefit

period ends when you haven’t received any

inpatient hospital care (or skilled care in a

SNF) for 60 days in a row, including your day

of discharge. If you go into a hospital or a

skilled nursing facility after one benefit

period has ended, a new benefit period

begins. There is no limit to the number of

benefit periods you can have.

Aetna Medicare Plan (PPO) 2023 Schedule of Cost Sharing

Services that are covered for you

What you must pay when you get these

services

present in the body, such as blood clotting factors.)

Blood – including storage and administration.

Coverage of whole blood and packed red cells

begins with the first pint of blood that you need. All

components of blood are covered beginning with

the first pint used.

•

Medical and surgical supplies ordinarily provided

by SNFs

•

Laboratory tests ordinarily provided by SNFs•

X‑rays and other radiology services ordinarily

provided by SNFs

•

Use of appliances such as wheelchairs ordinarily

provided by SNFs

•

Physician/Practitioner services•

Prior authorization rules apply for network services.

Your network provider is responsible for requesting

prior authorization. Our plan recommends

pre‑authorization of the service when provided by an

out‑of‑network provider.

Smoking and tobacco use cessation (counseling to

stop smoking or tobacco use)

If you use tobacco, but do not have signs or symptoms of

tobacco‑related disease: We cover two counseling quit

attempts within a 12‑month period as a preventive service

with no cost to you. Each counseling attempt includes up

to four face‑to‑face visits.

If you use tobacco and have been diagnosed with a

tobacco‑related disease or are taking medicine that may

be affected by tobacco: We cover cessation counseling

services. We cover two counseling quit attempts within a

12‑month period, however, you will pay the

applicablecost‑sharing. Each counseling attempt

includes up to four face‑to‑face visits.

In addition to Medicare‑covered benefits, we also offer:

Additional individual and group face‑to‑face

intermediate and intensive counseling sessions:

unlimited visits every year

•

There is no coinsurance, copayment, or

deductible for the Medicare‑covered

smoking and tobacco use cessation

preventive benefits.

$0 copay for each non‑Medicare covered

smoking and tobacco use cessation visit.

Special Supplemental Benefits for the Chronically Ill

Landmark providers: If you have been diagnosed by a

plan provider with generally six or more of the chronic

conditions listed below and you meet certain criteria, you

There is no coinsurance, copayment, or

deductible for this service.

Aetna Medicare Plan (PPO) 2023 Schedule of Cost Sharing

Services that are covered for you

What you must pay when you get these

services

may be eligible for in home and/or telehealth physician

services offered through Landmark providers:

Chronic alcohol and other drug dependence•

Autoimmune disorders•

Cancer•

Cardiovascular disorders•

Chronic heart failure•

Diabetes•

End stage liver disease•

End stage renal diseases (ESRD) requiring dialysis•

Chronic lung disorders•

Chronic and disabling mental health conditions•

Neurologic disorders•

Stroke•

Metabolic•

Vascular•

Musculoskeletal•

Aetna and/or Landmark will contact you by phone and/or

mail to notify you of your eligibility for this program. You

will be provided with additional information to help you

better understand the benefits offered by Landmark. This

is a voluntary program and you can decide if you want to

participate.

Supervised Exercise Therapy (SET)

SET is covered for members who have symptomatic

peripheral artery disease (PAD) and a referral for PAD

from the physician responsible for PAD treatment.



Up to 36 sessions over a 12‑week period are covered if

the SET program requirements are met.



The SET program must:

Consist of sessions lasting 30‑60 minutes,

comprising a therapeutic exercise‑training

program for PAD in patients with claudication

•

Be conducted in a hospital outpatient setting or a

physician’s office

•

Be delivered by qualified auxiliary personnel

necessary to ensure benefits exceed harms, and

who are trained in exercise therapy for PAD

•

Be under the direct supervision of a physician,

physician assistant, or nurse practitioner/clinical

•

$0 copay for each Medicare‑covered

supervised exercise therapy service.

Aetna Medicare Plan (PPO) 2023 Schedule of Cost Sharing

Services that are covered for you

What you must pay when you get these

services

nurse specialist who must be trained in both basic

and advanced life support techniques

SET may be covered beyond 36 sessions over 12 weeks

for an additional 36 sessions over an extended period of

time if deemed medically necessary by a health care

provider.

Transportation services (non‑emergency

transportation)

We cover:

24 one‑way trips to and from plan‑approved

locations each year

•

Trips must be within 60 miles of provider location.

Coverage includes trips to and from providers or facilities

for services that your plan covers. The transportation

service will accommodate urgent requests for hospital

discharge, dialysis, and trips that your medical provider

considers urgent. The service will try to accommodate

specific physical limitations or requirements. However, it

limits services to wheelchair, taxi, or sedan transportation

vehicles.

Transportation services are administered through

Access2Care

•

To arrange for transport, call 1‑855‑814‑1699,

Monday through Friday, from 8 AM to 8 PM, in all

time zones. (For TTY/TDD assistance please dial

711.)

•

You must schedule transportation service at least

48 hours before the appointment

•

You must cancel more than two hours in advance,

or Access2Care will deduct the trip from the

remaining number of trips available

•

This program doesn’t support stretcher

vans/ambulances

•

$0 copay per trip.

Urgently needed services

Urgently needed services are provided to treat a

non‑emergency, unforeseen medical illness, injury, or

condition that requires immediate medical care but given

your circumstances, it is not possible, or it is

unreasonable, to obtain services from network providers.

Examples of urgently needed services that the plan must

$15 copay for each urgent care facility visit.

Cost‑sharing is waived if you are admitted to

the hospital within 24 hours.

$15 copay for each urgent care telehealth

service.

Aetna Medicare Plan (PPO) 2023 Schedule of Cost Sharing

Services that are covered for you

What you must pay when you get these

services

cover out of network are i) you need immediate care

during the weekend, or ii) you are temporarily outside the

service area of the plan. Services must be immediately

needed and medically necessary.

Coverage is available worldwide (i.e., outside of the

United States).

Vision care

Covered services include:

Outpatient physician services for the diagnosis and

treatment of diseases and injuries of the eye,

including treatment for age‑related macular

degeneration. Original Medicare doesn’t cover

routine eye exams (eye refractions) for

eyeglasses/contacts

•

For people who are at high risk of glaucoma, we will

cover one glaucoma screening every 12 months.

People at high risk of glaucoma include: people

with a family history of glaucoma, people with

diabetes, African Americans who are age 50 and

older, and Hispanic Americans who are 65 or older

•

For people with diabetes, screening for diabetic

retinopathy is covered once per year

•

One pair of eyeglasses or contact lenses after each

cataract surgery that includes insertion of an

intraocular lens. (If you have two separate cataract

operations, you cannot reserve the benefit after the

first surgery and purchase two eyeglasses after the

second surgery.)

•

In addition to Medicare‑covered benefits, we also offer:

Non‑Medicare covered eye exams: one exam every

year

•

Follow‑up diabetic eye exam•

$15 copay for exams to diagnose and treat

diseases and conditions of the eye.



$0 copay for each Medicare‑covered

glaucoma screening.

$0 copay for one diabetic retinopathy

screening.

$0 copay for each follow‑up diabetic eye

exam.

$0 copay for one pair of eyeglasses or

contact lenses after each cataract surgery.

Coverage includes conventional eyeglasses

or contact lenses. Excluded is coverage for

designer frames and progressive lenses

instead of traditional lenses, bifocals, or

trifocals.

$0 copay for each non‑Medicare covered

eye exam.

Additional cost‑sharing may apply if you

receive additional services during your visit.

“Welcome to Medicare” preventive visit

The plan covers the one‑time “Welcome to Medicare”

preventive visit. The visit includes a review of your health,

as well as education and counseling about the preventive

services you need (including certain screenings and

shots), and referrals for other care if needed.



Important: We cover the “Welcome to Medicare”

preventive visit only within the first 12 months you have

Medicare Part B. When you make your appointment, let

your doctor’s office know you would like to schedule your

There is no coinsurance, copayment, or

deductible for the “Welcome to Medicare”

preventive visit.

$0 copay for a Medicare‑covered EKG

screening following the "Welcome to

Medicare" preventive visit.

Aetna Medicare Plan (PPO) 2023 Schedule of Cost Sharing

Services that are covered for you

What you must pay when you get these

services

“Welcome to Medicare” preventive visit.

Note: See Chapter 4, Section 2.1 of the Evidence of Coverage for information on prior authorization rules.

Aetna Medicare Plan (PPO) Member Services

Method Member Services – Contact Information

CALL

The number on your member ID card or 1‑855‑648‑0389

Calls to this number are free.

Hours of operation are 8 AM to 9 PM ET, Monday through

Friday

Member Services also has free language interpreter services

available for non‑English speakers.

TTY

711

Calls to this number are free.

Hours of operation are 8 AM to 9 PM ET, Monday through Friday

WRITE

Aetna Medicare

PO Box 7082

London, KY 40742

WEBSITE

CONY.AetnaMedicare.com.

State Health Insurance Assistance Program (SHIP)

SHIP is a state program that gets money from the Federal government to give free local health insurance

counseling to people with Medicare. Contact information for your state’s SHIP is in Addendum A at the

back of your Evidence of Coverage booklet.

PRA Disclosure StatementAccording to the Paperwork Reduction Act of 1995, no persons are required to

respond to a collection of information unless it displays a valid OMB control number. The valid OMB control

number for this information collection is 0938‑1051. If you have comments or suggestions for improving this

form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop

C4‑26‑05, Baltimore, Maryland 21244‑1850.

Form Approved

OMB#0938-1421

Multi-Language Insert

Multi-language Interpreter Services

English: We have free interpreter services to answer any questions you may have about our health or

drug plan. To get an interpreter, just call us at 1-888-267-2637. Someone who speaks English/Language

can help you. This is a free service.

Spanish:Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda

tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al 1-

888-267-2637. Alguien que hable español le podrá ayudar. Este es un servicio gratuito.

Chinese Mandarin:我们提供免费的翻译服务，帮助您解答关于健康或药物保险的任何疑问。如果您需要此翻

译服务，请致电 1-888-267-2637。我们的中文工作人员很乐意帮助您。这是一项免费服务。

Chinese Cantonese:您對我們的健康或藥物保險可能存有疑問，為此我們提供免費的翻譯服務。如需翻譯服

務，請致電 1-888-267-2637。我們講中文的人員將樂意為您提供幫助。這是一項免費服務。

Tagalog:Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga

katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng

tagasaling-wika, tawagan lamang kami sa 1-888-267-2637. Maaari kayong tulungan ng isang

nakakapagsalita ng Tagalog. Ito ay libreng serbisyo.

French:Nous proposons des services gratuits d'interprétation pour répondre à toutes vos questions

relatives à notre régime de santé ou d'assurance-médicaments. Pour accéder au service d'interprétation,

il vous suffit de nous appeler au 1-888-267-2637. Un interlocuteur parlant Français pourra vous aider. Ce

service est gratuit.

Vietnamese:Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức khỏe và chương

trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi 1-888-267-2637. sẽ có nhân viên nói tiếng Việt giúp đỡ

quí vị. Đây là dịch vụ miễn phí .

German:Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und

Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1-888-267-2637. Man wird Ihnen dort auf

Deutsch weiterhelfen. Dieser Service ist kostenlos.

Korean:당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습니

다. 통역 서비스를 이용하려면 전화 1-888-267-2637. 번으로 문의해 주십시오. 한국어를 하는 담당자가 도와

드릴 것입니다. 이 서비스는 무료로 운영됩니다.

Russian:Если у вас возникнут вопросы относительно страхового или медикаментного плана, вы

можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться

услугами переводчика, позвоните нам по телефону 1-888-267-2637. Вам окажет помощь сотрудник,

который говорит по-pусски. Данная услуга бесплатная.

1-888-267-2637



Hindi:     

 





Italian:È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro

piano sanitario e farmaceutico. Per un interprete, contattare il numero 1-888-267-2637. Un nostro

incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio gratuito.



Portuguese:Dispomos de serviços de interpretação gratuitos para responder a qualquer questão que

tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte-nos através

do número 1-888-267-2637. Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço

é gratuito.



French Creole:Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan

medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan 1-888-267-2637. Yon moun ki pale

Kreyòl kapab ede w. Sa a se yon sèvis ki gratis.



Polish:Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w uzyskaniu

odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z pomocy tłumacza

znającego język polski, należy zadzwonić pod numer 1-888-267-2637. Ta usługa jest bezpłatna.



Japanese:当社の健康健康保険と薬品処方薬プランに関するご質問にお答えするために、無料の通訳サー

ビスがありますございます。通訳をご用命になるには、1-888-267-2637. にお電話ください。日本語を話す人

者が支援いたします。これは無料のサービスです。



Hawaiian:He kōkua māhele ʻōlelo kā mākou i mea e pane ʻia ai kāu mau nīnau e pili ana i kā mākou

papahana olakino a lāʻau lapaʻau paha. I mea e loaʻa ai ke kōkua māhele ʻōlelo, e kelepona mai iā mākou ma

1-888-267-2637. E hiki ana i kekahi mea ʻōlelo Pelekānia/ʻŌlelo ke kōkua iā ʻoe. He pōmaikaʻi manuahi kēia.



Y0001_NR_30475b_2023_C

Form CMS-10802

(Expires 12/31/25)