RFP 27-10/AB MEDICARE ADVANTAGE

CITY OF HAMPTON
Aetna MedicareSM Plan (PPO)
Medicare (P01) ESA PPO Plan
Rx $10/$30/$45/$45
Benefits and Premiums are effective January 1, 2026 through December 31, 2026
SUMMARY OF BENEFITS
PROVIDED BY AETNA LIFE INSURANCE COMPANY
Primary Care Physician (PCP): You have the option to choose a PCP. When we know who your
provider is, we can better support your care.
Referrals: Your plan doesn't require a referral from a PCP to see a specialist. Keep in mind, some
providers may require a recommendation or treatment plan from your doctor in order to see you.
Prior Authorizations: Your doctor will work with us to get approval before you receive certain
services or drugs. Benefits that may require a prior authorization are listed with an asterisk (*) in the
benefits grid.
PLAN FEATURES Network & out-of-network providers.
Monthly Premium Please contact your former employer/union/trust for
more information on your plan premium.
Plan Follows the Federal Medicare Part B No
Deductible
Plan deductible is equal to the Federal
Medicare Part B deductible
Annual Deductible $200
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.
Services Exempt from Deductible:
Annual wellness exams, routine physical exam, routine mammograms, diagnostic mammogram,
routine hearing exam, routine colorectal screening, routine prostate screening, bone mass
measurement, immunization, routine GYN, routine eye care, kidney disease education, Medicare
diabetic prevention program (MDPP), Medicare-covered $0 preventive services, additional
Medicare preventive care services, Part B Drugs - Insulin, Continuous Glucose Monitors (CGMs),
emergency room, emergency ambulance services, some Medicare-covered diagnostic tests and
labs (Urine protein, Prothrombin testing, HBA1C, FIT Screening, Fundus Testing, gFOBT Testing and
COVID lab tests), Wigs, Teladoc, and urgently needed care.
Annual Maximum Out-of-Pocket Amount
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CITY OF HAMPTON
Aetna MedicareSM Plan (PPO)
Medicare (P01) ESA PPO Plan
Rx $10/$30/$45/$45
Annual maximum out-of-pocket limit amount $1,000
includes any deductible, copayment or
coinsurance that you pay.
It will apply to all medical expenses except Hearing Aid Reimbursement and Medicare prescription
drug coverage that may be available on your plan.
HOSPITAL CARE* This is what you pay for network & out-of-
network providers.
Inpatient Hospital Care $0 per stay
The member cost sharing applies to covered benefits incurred during a member's inpatient stay.
Observation Stay Your cost share for Observation Care is based upon
the services you receive
Frequency: per stay
Outpatient Services & Surgery $0
Ambulatory Surgery Center $0
PHYSICIAN SERVICES This is what you pay for network & out-of-
network providers.
Primary Care Physician Visits $20
Includes services of an internist, general physician, family practitioner for routine care as well as
diagnosis and treatment of an illness or injury and in-office surgery.
Physician Specialist Visits $35
PREVENTIVE CARE This is what you pay for network & out-of-
network providers.
Medicare-covered Preventive Services $0
* Abdominal aortic aneurysm screenings
* Alcohol misuse screenings and counseling
* Annual Well Visit - One exam every 12 months.
* Bone mass measurements
* Breast exams
* Breast cancer screening: mammogram - one baseline mammogram for members age 35-39; and
one annual mammogram for members age 40 & over.
* Cardiovascular behavior therapy
* Cardiovascular disease screenings
* Cervical and vaginal cancer screenings (Pap) - one routine GYN visit and pap smear every 24
months.
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CITY OF HAMPTON
Aetna MedicareSM Plan (PPO)
Medicare (P01) ESA PPO Plan
Rx $10/$30/$45/$45
* Colorectal cancer screenings (colonoscopy, fecal occult blood test, flexible sigmoidoscopy)
* Depression screenings
* Diabetes screenings
* HBV infection screening
* Hepatitis C screening tests
* HIV screenings
* Lung cancer screenings and counseling
* Medicare Diabetes Prevention Program - 12 months of core session for program eligible members
with an indication of pre-diabetes.
* Nutrition therapy services
* Obesity behavior therapy
* Pelvic Exams and pap test (screening) - one routine GYN visit and pap smear every 24 months.
* Prolonged Preventive Services - prolonged preventive service(s) (beyond the typical service time
of the primary procedure), in the office or other outpatient setting requiring direct patient contact
beyond the usual service
* Prostate cancer screenings (PSA) - for all male patients aged 50 and older (coverage begins the
day after 50th birthday)
* Sexually transmitted infections screenings and counseling
* Tobacco use cessation counseling
* Welcome to Medicare preventive visit
Immunizations $0
* Flu
* Hepatitis B
* Pneumococcal
Additional Medicare Preventive Services $0
* Diabetes self-management training (DSMT)
* Digital rectal exam (DRE)
* EKG following welcome exam
* Glaucoma screening
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CITY OF HAMPTON
Aetna MedicareSM Plan (PPO)
Medicare (P01) ESA PPO Plan
Rx $10/$30/$45/$45
EMERGENCY AND URGENT MEDICAL CARE This is what you pay for network & out-of-
network providers.
Emergency Care; Worldwide $0
(waived if admitted)
Urgently Needed Care; Worldwide $0
DIAGNOSTIC PROCEDURES* This is what you pay for network & out-of-
network providers.
Diagnostic Radiology $0
CT scans
Diagnostic Radiology $0
Other than CT scans
Lab Services $0
Diagnostic testing & procedures $0
Outpatient X-rays $0
HEARING SERVICES This is what you pay for network & out-of-
network providers.
Routine Hearing Screening $0
We cover one exam every twelve months
Medicare Covered Hearing Examination $35
Hearing Aid Reimbursement $500 once every 36 months
DENTAL SERVICES This is what you pay for network & out-of-
network providers.
Medicare Covered Dental* $35
Non-routine care covered by Medicare.
VISION SERVICES This is what you pay for network & out-of-
network providers.
Routine Eye Exams $35
One annual exam every 12 months.
Diabetic Eye Exams $0
Medicare Covered Eye Exam $35
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CITY OF HAMPTON
Aetna MedicareSM Plan (PPO)
Medicare (P01) ESA PPO Plan
Rx $10/$30/$45/$45
MENTAL HEALTH SERVICES* This is what you pay for network & out-of-
network providers.
Inpatient Mental Health Care $0 per stay
The member cost sharing applies to covered benefits incurred during a member's inpatient stay.
Outpatient Mental Health Care $0
Individual visit
Partial Hospitalization $0
Intensive Outpatient Services $0
Inpatient Substance Abuse $0 per stay
The member cost sharing applies to covered benefits incurred during a member's inpatient stay.
Outpatient Substance Abuse $0
Individual visit
SKILLED NURSING SERVICES* This is what you pay for network & out-of-
network providers.
Skilled Nursing Facility (SNF) Care $0 per day, days 1-100
Limited to 100 days per Medicare Benefit Period.
The member cost sharing applies to covered benefits incurred during a member's inpatient 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. 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.
PHYSICAL THERAPY SERVICES* This is what you pay for network & out-of-
network providers.
Outpatient Rehabilitation Services $0
(Speech, physical, and occupational therapy)
AMBULANCE SERVICES This is what you pay for network & out-of-
network providers.
Ambulance Services $0
Prior authorization rules may apply for non-emergency transportation services received in-network.
Your network provider is responsible for requesting prior authorization. Our plan recommends pre-
authorization of non-emergency transportation services when provided by an out-of-network
provider.
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CITY OF HAMPTON
Aetna MedicareSM Plan (PPO)
Medicare (P01) ESA PPO Plan
Rx $10/$30/$45/$45
TRANSPORTATION SERVICES This is what you pay for network & out-of-
network providers.
Transportation (non-emergency) Not Covered
MEDICARE PART B PRESCRIPTION DRUGS* This is what you pay for network & out-of-
network providers.
Medicare Part B Prescription Drugs $0
Medicare Part B Prescription Drugs - Insulin $0
MEDICARE PART D PRESCRIPTION DRUGS This is what you pay for network & out-of-
network providers.
Part D drugs are covered. See PHARMACY - PRESCRIPTION DRUG BENEFITS section below for
your plan benefits at each part D stage, including cost share and other important pharmacy
benefit information.
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CITY OF HAMPTON
Aetna MedicareSM Plan (PPO)
Medicare (P01) ESA PPO Plan
Rx $10/$30/$45/$45
ADDITIONAL PROGRAMS AND SERVICES This is what you pay for network & out-of-
network providers.
Allergy Shots $0
Allergy Testing $35
Blood $0
All components of blood are covered beginning with the first pint.
Cardiac Rehabilitation Services $0
Intensive Cardiac Rehabilitation Services $0
Chiropractic Services* $20
Medicare covered benefits only.
Diabetic Supplies* $0
Includes supplies to monitor your blood glucose.
Durable Medical Equipment/ Prosthetic $0
Devices*
Home Health Agency Care* $0
Hospice Care Covered by Original Medicare at a Medicare certified
hospice.
Medical Supplies* $0
Medicare Covered Acupuncture $35
Outpatient Dialysis Treatments* $0
Podiatry Services $35
Medicare covered benefits only.
Pulmonary Rehabilitation Services $0
Supervised Exercise Therapy (SET) for PAD $0
Services
Radiation Therapy* $0
ADDITIONAL PROGRAMS (NOT COVERED This is what you pay for network & out-of-
BY ORIGINAL MEDICARE) network providers.
Fitness Benefit SilverSneakers(R)
Resources For Living(R) Covered
For help locating resources for every day needs.
Smoking and Tobacco Use Cessation $0
Supplies
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CITY OF HAMPTON
Aetna MedicareSM Plan (PPO)
Medicare (P01) ESA PPO Plan
Rx $10/$30/$45/$45
Frequency unlimited visits every
year
Teladoc(TM) $0
Telemedicine services with a Teladoc(TM) provider. State mandates may apply.
Telehealth Covered
Telemedicine Services. Member cost share will apply based on services rendered.
Telehealth PCP $20
Telehealth Specialist $35
Telehealth Occupational Therapy Services $0
Telehealth PT and SP Services $0
Telehealth Other Health care Providers $35
Telehealth Individual Mental Health $0
Telehealth Group Mental Health $0
Telehealth Individual Psychiatric Services $0
Telehealth Group Psychiatric Services $0
Telehealth Individual Substance Abuse $0
Services
Telehealth Group Substance Abuse Services $0
Telehealth Kidney Disease Education Services $0
Telehealth Diabetes Self-Management $0
Training
Telehealth Opioid Treatment Program $0
Services
Telehealth Urgent care $0
Wigs* $0
Maximum $400
Frequency every year
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CITY OF HAMPTON
Aetna MedicareSM Plan (PPO)
Medicare (P01) ESA PPO Plan
Rx $10/$30/$45/$45
ADDITIONAL SERVICES (NOT COVERED BY This is what you pay for network & out-of-
ORIGINAL MEDICARE) network providers.
Enhanced Chiropractic Services $20
Visits: unlimited visits every year
Foot Orthotics $0
Routine Podiatry $35
Frequency unlimited visits every year
Routine Physical Exams $0
One exam per calendar year
Private Duty Nursing* 20%
Benefit Frequency every year
Benefit Maximum $500
Benefits that may require a prior authorization are listed with an asterisk (*) in the benefits grid.
See next page for Pharmacy-Prescription Drug Benefits.
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CITY OF HAMPTON
Aetna MedicareSM Plan (PPO)
Medicare (P01) ESA PPO Plan
Rx $10/$30/$45/$45
PHARMACY - PRESCRIPTION DRUG BENEFITS
Pharmacy Network P1
Your Medicare Part D plan uses the network above. To find a network pharmacy, you can visit our
website (http://www.aetnaretireeplans.com.)
Formulary (Drug List) Comprehensive Plus
Calendar-Year Deductible for Prescription Drugs $0
Prescription drug calendar year deductible must be satisfied before any Medicare Prescription Drug
benefits are paid. Covered Medicare Prescription Drug expenses will accumulate toward the
pharmacy deductible. The deductible does not apply to covered insulins and most Part D vaccines.
Initial Coverage Phase - The table below represents cost sharing after the deductible, if applicable,
has been reached.
30-day Supply through
90-day Supply through Retail or Mail
Retail
4 Tier Plan Preferred Standard Preferred Preferred Standard
Retail Mail Retail or Mail
Tier 1 - Generic $5 $10 $10 $10 $20
Generic Drugs
Tier 2 - Preferred Brand $30 $30 $60 $60 $60
Preferred Brand Drugs
Tier 3 - Non-Preferred $45 $45 $90 $90 $90
Brand
Non-Preferred Brand
Drugs
Tier 4 - Specialty $45 $45 $90 $90 $90
Includes high-
cost/unique generic and
brand drugs
If you reside in a long-term care facility, your cost share is the same as a 30 day supply at a retail
pharmacy and you may receive up to a 31 day supply.
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