2019 Gold Advantage Value (HMO) H2663-032-000 in IL from Aetna | HealthPocket

Gold Advantage Value (HMO)

$0/mo

Benefits & Coverage

Insurance TypeMedicare Advantage Plan (Part C w/ RX)
Insurance ProviderAetna
Plan IDH2663-032-000
Plan Year2019
CMS Rating
Plan TypeHMO
Annual Deductible$0.00
Out-of-Pocket Maximum3400

What To Know About This Plan
  • This plan has health and drug coverage
  • This plan is available for 2021. see plan

Why We Like This Plan
  • has both Health and Drug Coverage
  • has no additional premium costs outside of your Medicare Part B premium

Costs and Other Important Information

Plan Year2019
Monthly Health Plan Premium$0.00
Monthly Drug Plan Premium$0.00
Health Plan Deductible$0
Other health plan deductibles?No
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)$3,400 In-network
Optional Supplemental BenefitsYes

Benefits

SERVICECOST
Inpatient hospital coverage$260 per day for days 1 through 5
$0 per day for days 6 through 90
Outpatient hospital coverage$300 per visit
Doctor visitsPrimary:$10 per visit
Specialist:$40 per visit
Preventive care$0 copay
Emergency care/Urgent careEmergency:$90 per visit (always covered)
Urgent care:$65 per visit (always covered)
Diagnostic procedures/lab services/imagingDiagnostic tests and procedures:$150
Lab services:$0 copay
Diagnostic radiology services (e.g., MRI):$40-190
Outpatient x-rays:$10
Mental health servicesInpatient hospital - psychiatric:$260 per day for days 1 through 5
$0 per day for days 6 through 90
Outpatient group therapy visit with a psychiatrist:$40
Outpatient individual therapy visit with a psychiatrist:$40
Outpatient group therapy visit:$40
Outpatient individual therapy visit:$40
Skilled Nursing Facility$0 per day for days 1 through 20
$167 per day for days 21 through 100
Rehabilitation servicesOccupational therapy visit:$40
Physical therapy and speech and language therapy visit:$40
Ground ambulance$285
TransportationNot covered
Foot care (podiatry services)Foot exams and treatment:$40
Routine foot care:$40There may be limits on how much the plan will provide.
Medical equipment/suppliesDurable medical equipment (e.g., wheelchairs, oxygen):20% per item
Prosthetics (e.g., braces, artificial limbs):20% per item
Diabetes supplies:0-20% per item
Wellness programs (e.g., fitness, nursing hotline)Covered
Medicare Part B drugsChemotherapy:20%
Other Part B drugs:20%

Benefits Services

Hearing
Hearing exam$40
Fitting/evaluation$0 copay. There may be limits on how much the plan will provide.
Hearing aids$0 copay. There may be limits on how much the plan will provide.
Preventive Dental
Oral exam$0 copay. There may be limits on how much the plan will provide.
Cleaning$0 copay. There may be limits on how much the plan will provide.
Fluoride treatmentNot covered
Dental x-ray(s)$0 copay. There may be limits on how much the plan will provide.
Comprehensive Dental
Non-routine servicesNot covered
Diagnostic servicesNot covered
Restorative servicesNot covered
EndodonticsNot covered
PeriodonticsNot covered
ExtractionsNot covered
Prosthodontics, other oral/maxillofacial surgery, other servicesNot covered
Vision
Routine eye exam$0 copay. There may be limits on how much the plan will provide.
OtherNot covered
Contact lenses$0 copay. There may be limits on how much the plan will provide.
Eyeglasses (frames and lenses)$0 copay. There may be limits on how much the plan will provide.
Eyeglass frames$0 copay. There may be limits on how much the plan will provide.
Eyeglass lenses$0 copay. There may be limits on how much the plan will provide.
Upgrades$0 copay. There may be limits on how much the plan will provide.

Coverage Area for Gold Advantage Value (HMO)

StateIllinois
CountyCook

All cost-sharing assumes in-network healthcare providers.
Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit


30 Day SupplyPreferred Retail Pharmacies Drug CostStandard Retail Pharmacies Drug CostPreferred Mail-Order Drug CostStandard Mail-Order Drug Cost
Tier 1: Preferred GenericNot offereds$3 copayNot offered
Tier 2: Non-Preferred GenericNot offereds$7 copayNot offered
Tier 3: Preferred Brand NameNot offereds$47 copayNot offered
Tier 4: Non-Preferred Brand NameNot offereds$100 copayNot offered
Tier 5: Specialty TierNot offereds33% coinsuranceNot offered
Tier 6: Select Care Drugs

60 Day SupplyPreferred Retail Pharmacies Drug CostStandard Retail Pharmacies Drug CostPreferred Mail-Order Drug CostStandard Mail-Order Drug Cost
Tier 1: Preferred GenericNot offereds$6 copayNot offered
Tier 2: Non-Preferred GenericNot offereds$14 copayNot offered
Tier 3: Preferred Brand NameNot offereds$94 copayNot offered
Tier 4: Non-Preferred Brand NameNot offereds$200 copayNot offered
Tier 5: Specialty Tier
Tier 6: Select Care Drugs
90 Day SupplyPreferred Retail Pharmacies Drug CostStandard Retail Pharmacies Drug CostPreferred Mail-Order Drug CostStandard Mail-Order Drug Cost
Tier 1: Preferred GenericNot offereds$0 copayNot offered
Tier 2: Non-Preferred GenericNot offereds$0 copayNot offered
Tier 3: Preferred Brand NameNot offereds$141 copayNot offered
Tier 4: Non-Preferred Brand NameNot offereds$300 copayNot offered
Tier 5: Specialty Tier
Tier 6: Select Care Drugs

Physicians that accept Gold Advantage Value (HMO) for Illinois

/
Please select the correct zip
Chia, Huang
View All Details
Andree, De Bustros
View All Details
Melinda, Gibson
View All Details
Theodore, Christou
View All Details
Lisa, Daniel
View All Details
Ashley, Ferrell
View All Details
Kenyatta, Frazier
View All Details
Erin, Jamen
View All Details
Karen, Raden
View All Details
Jennifer, Perez
View All Details
Parakrama, De Silva
View All Details
Smain, Sadok
View All Details
Chia Huang, MD
View All Details
  • Phone Number
    (773) 735-4884
  • Office Locations
    2701 W 68th St
    Chicago, IL 60629
2701 W 68th St Chicago IL, 60629

HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, or an individual and family health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. HealthPocket, Inc. is part of the Benefytt Technologies, Inc. family of companies.

Medicare Plans Found

 

HealthPocket.com provides information on insurance products. If you choose to obtain a quote or apply for an insurance plan, you may be transferred to a partner website to complete your request. Always review the privacy and terms of use of the partner website.

HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, or an individual and family health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. HealthPocket, Inc. is part of the Benefytt Technologies, Inc. family of companies.