January 1, 2016 – December 31, 2016 Summary Of Benefits

January 1, 2016 – December 31, 2016Summaryof BenefitsAetna Medicare Elite Plan (HMO)H5793-011H5793.011.1Y0001 2016 H5793 011 Accepted 9/2015

Summary of BenefitsJanuary 1, 2016 – December 31, 2016This booklet gives you a summary of what we cover and what you pay. It doesn't list every servicethat we cover or list every limitation or exclusion. To get a complete list of services we cover, call usand ask for the "Evidence of Coverage."You have choices about how to get yourMedicare benefits1 One choice is to get your Medicare benefitsthrough Original Medicare (fee-for-serviceMedicare). Original Medicare is run directly bythe Federal government.1 Another choice is to get your Medicare benefitsby joining a Medicare health plan (such asAetna Medicare Elite Plan (HMO)).Tips for comparing your Medicare choicesThis Summary of Benefits booklet gives you asummary of what Aetna Medicare Elite Plan(HMO) covers and what you pay.This document is available in other formats suchas Braille and large print.This document may be available in a non-Englishlanguage. For additional information, call us at1-855-338-7027, TTY: 711.Este documento está disponible en otros formatoscomo Braille y en letra grande.Este documento puede estar disponible en unidioma diferente al inglés. Para informaciónadicional, llámenos al 1-855-338-9533, TTY 711.Things to Know About Aetna Medicare Elite Plan(HMO)Hours of Operation1 If you want to compare our plan with other1 From October 1 to February 14, you can callMedicare health plans, ask the other plans forus 7 days a week from 8:00 a.m. to 8:00 p.m.their Summary of Benefits booklets. Or, useLocal time.the Medicare Plan Finder on http://1 From February 15 to September 30, you canwww.medicare.gov.call us Monday through Friday from 8:00 a.m.1 If you want to know more about the coverageto 8:00 p.m. Local time.and costs of Original Medicare, look in yourcurrent "Medicare & You" handbook. View it Aetna Medicare Elite Plan (HMO) PhoneNumbers and Websiteonline at http://www.medicare.gov or get a1 If you are a member of this plan, call toll-freecopy by calling 1-800-MEDICARE1-800-282-5366, TTY: 711.(1-800-633-4227), 24 hours a day, 7 days a1 If you are not a member of this plan, callweek. TTY users should call 1-877-486-2048.toll-free 1-855-338-7027, TTY: 711.Sections in this booklet1 Our website: http://www.aetnamedicare.com1 Things to Know About Aetna Medicare EliteWho can join?Plan (HMO)1 Monthly Premium, Deductible, and Limits on To join Aetna Medicare Elite Plan (HMO), youmust be entitled to Medicare Part A, be enrolledHow Much You Pay for Covered Servicesin Medicare Part B, and live in our service area.1 Covered Medical and Hospital Benefits1 Prescription Drug Benefits

Our service area includes the following countiesin Connecticut: Hartford, Litchfield, and Tolland.1 You can see the complete plan formulary (listof Part D prescription drugs) and anyrestrictions on our website, http://www.aetnamedicare.com/2016formulary.1 Or, call us and we will send you a copy of theformulary.Which doctors, hospitals, and pharmacies can Iuse?Aetna Medicare Elite Plan (HMO) has a networkof doctors, hospitals, pharmacies, and otherproviders. If you use the providers that are not in How will I determine my drug costs?our network, the plan may not pay for theseOur plan groups each medication into one of fiveservices."tiers." You will need to use your formulary tolocate what tier your drug is on to determine howYou must generally use network pharmacies tomuch it will cost you. The amount you payfill your prescriptions for covered Part D drugs.depends on the drug's tier and what stage of theSome of our network pharmacies have preferred benefit you have reached. Later in this documentcost-sharing. You may pay less if you use thesewe discuss the benefit stages that occur: Initialpharmacies.Coverage, Coverage Gap, and CatastrophicYou can see our plan's provider directory at our Coverage.website (http://www.AetnaMedicareDocFind.com).You can see our plan's pharmacy directory at ourwebsite , call us and we will send you a copy of theprovider and pharmacy directories.What do we cover?Like all Medicare health plans, we covereverything that Original Medicare covers - andmore.1 Our plan members get all of the benefitscovered by Original Medicare. For some ofthese benefits, you may pay more in our planthan you would in Original Medicare. Forothers, you may pay less.1 Our plan members also get more than whatis covered by Original Medicare. Some of theextra benefits are outlined in this booklet.We cover Part D drugs. In addition, we coverPart B drugs such as chemotherapy and somedrugs administered by your provider.

Summary of BenefitsJanuary 1, 2016 – December 31, 2016Aetna Medicare Elite Plan (HMO)Monthly Premium, Deductible, and Limits on How Much You Pay for Covered ServicesHow much is the 0 per month. In addition, you must keep paying your Medicare Part Bmonthly premium?premium.How much is thedeductible?This plan has deductibles for some hospital and medical services. 1,000 per year for in-network services.This plan does not have a deductible for Part D prescription drugs.Is there any limit onYes. Like all Medicare health plans, our plan protects you by having yearlyhow much I will pay for limits on your out-of-pocket costs for medical and hospital care.my covered services?Your yearly limit(s) in this plan:1 6,700 for services you receive from in-network providers.If you reach the limit on out-of-pocket costs, you keep getting coveredhospital and medical services and we will pay the full cost for the rest ofthe year.Please note that you will still need to pay your monthly premiums andcost-sharing for your Part D prescription drugs.Is there a limit on how Our plan has a coverage limit every year for certain in-network benefits.much the plan willContact us for the services that apply.pay?Aetna Medicare is a PDP, HMO, PPO plan with a Medicare contract. Our SNPs also have contractswith State Medicaid programs. Enrollment in our plans depends on contract renewal.Covered Medical and Hospital BenefitsNote:1 Services with a 1 may require prior authorization.1 Services with a 2 may require a referral from your doctor.Outpatient Care and ServicesAcupunctureNot coveredAmbulance1 300 copayChiropractic Care1,2Manipulation of the spine to correct a subluxation (when 1 or more of thebones of your spine move out of position): 20 copayThe 1,000 Annual In Network Deductible does not apply to these services.

Aetna Medicare Elite Plan (HMO)Dental Services1Limited dental services (this does not include services in connection withcare, treatment, filling, removal, or replacement of teeth): 35 copayPreventive dental services:1 Cleaning: 0 copay1 Dental x-ray(s): 0 copay1 Oral exam: 0 copayOur plan pays up to 175 every year for preventive dental services.Our plan pays up to 175 a year for dental services. You can see anylicensed dental provider. You will need to pay the dentist at the time ofservice and send us an itemized bill with a request for payment. The 1,000Annual In Network Deductible does not apply to these services.Diabetes Supplies andServices1,2Diabetes monitoring supplies: 0-20% of the cost, depending on the supplyDiabetes self-management training: You pay nothingTherapeutic shoes or inserts: You pay nothingYou pay a 0 copayment for glucose monitors and diabetic test strips fromour preferred vendor, OneTouch/LifeScan. You will pay 20% of the costof glucose monitors and diabetic test strips from non-preferred vendors.The 1,000 annual in-network deductible does not apply to these costs.Diagnostic Tests, Laband Radiology Services,and X-Rays (Costs forthese services may bedifferent if received inan outpatient surgerysetting)1,2Diagnostic radiology services (such as MRIs, CT scans): 150 copayDiagnostic tests and procedures: 40 copayLab services: 10 copayOutpatient x-rays: 20 copayTherapeutic radiology services (such as radiation treatment for cancer):20% of the costThe 1,000 Annual In Network Deductible does not apply to DiagnosticTests, Lab and X-Rays services. It does apply to Radiology Services (suchas CT Scans, MRI's, MRA's, etc.) and Therapeutic Radiology services.Doctor's Office Visits2Primary care physician visit: 10 copaySpecialist visit: 35 copayThe 1,000 Annual In Network Deductible does not apply to these services.Durable MedicalEquipment20% of the cost

Aetna Medicare Elite Plan (HMO)(wheelchairs, oxygen,etc.)1The 1,000 Annual In Network Deductible does not apply to these services.Emergency Care 75 copayIf you are immediately admitted to the hospital, you do not have to payyour share of the cost for emergency care. See the "Inpatient HospitalCare" section of this booklet for other costs.The 1,000 Annual In Network Deductible does not apply to these services.Foot Care (podiatryservices)2Foot exams and treatment if you have diabetes-related nerve damageand/or meet certain conditions: 35 copayThe 1,000 Annual In Network Deductible does not apply to these services.Hearing Services2Exam to diagnose and treat hearing and balance issues: 35 copayRoutine hearing exam (for up to 1 every year): 0 copayHearing aid fitting/evaluation: 35 copayHearing aid: 0 copayOur plan pays up to 800 every three years for hearing aids.You pay a 0 copay for routine hearing exams. We pay up to 800 every3 years toward the cost of hearing aids. The 1,000 Annual In NetworkDeductible does not apply.Home Health Care1You pay nothingThe 1,000 Annual In Network Deductible does not apply to these services.Mental Health Care1Inpatient visit:Our plan covers up to 190 days in a lifetime for inpatient mental healthcare in a psychiatric hospital. The inpatient hospital care limit does notapply to inpatient mental services provided in a general hospital.Our plan covers 90 days for an inpatient hospital stay.Our plan also covers 60 "lifetime reserve days." These are "extra" daysthat we cover. If your hospital stay is longer than 90 days, you can usethese extra days. But once you have used up these extra 60 days, yourinpatient hospital coverage will be limited to 90 days.1 1,528 copay per stayOutpatient group therapy visit: 40 copay

Aetna Medicare Elite Plan (HMO)Mental Health Care1Outpatient individual therapy visit: 40 copayInpatient mental health hospitalization: You pay your cost share peradmission; The 1,000 Annual In Network Deductible does not apply tooutpatient group and individual therapy visits.OutpatientRehabilitation1,2Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions perday for up to 36 sessions up to 36 weeks): 35 copayOccupational therapy visit: 35 copayPhysical therapy and speech and language therapy visit: 35 copayThe 1,000 Annual In Network Deductible does not apply to these services.Outpatient SubstanceAbuse1Group therapy visit: 35 copayIndividual therapy visit: 35 copayThe 1,000 Annual In Network Deductible does not apply to these services.Outpatient Surgery1Ambulatory surgical center: 150 copayOutpatient hospital: 35-150 copay, depending on the serviceThe minimum copay will apply to Medicare-covered outpatient hospitalservices other than surgery. The maximum copay will apply toMedicare-covered outpatient hospital surgery.Over-the-Counter Items Not CoveredProsthetic DevicesProsthetic devices: 20% of the cost(braces, artificial limbs,Related medical supplies: 35 copayetc.)1The 1,000 Annual In Network Deductible does not apply to these services.Renal Dialysis120% of the costTransportationNot coveredUrgently NeededServices 10-35 copay, depending on the serviceThe minimum copay would apply for urgently needed care received by aPCP that is assigned to or selected by the member, the maximum copaywould apply for urgently needed care received at an Urgent Care facility.The 1,000 Annual In Network Deductible does not apply to these services.