5

5 out of 5 stars* for plan year 2024

Plan ID: H5521-122

What You Need to Know:

  • Aetna Medicare Gold Plan (PPO) is a Medicare Advantage Health Maintenance Organization Local PPO plan.
  • It must provide all of the same hospital and medical benefits as Medicare Part A and Part B, however, costs may be different.
  • It has additional benefits not included in Medicare Part A and Part B, including prescription drug coverage.
  • The plan's monthly premium is $169, which does not include your monthly Medicare Part B premium.
  • The annual deductible for this health plan is .
  • The plan includes an out-of-pocket maximum of $7,550 per year (in-network).
  • Aetna Medicare Gold Plan (PPO) includes a Part D prescription drug plan for prescription medication coverage. The annual deductible is .
  • This plan's Part D Initial Coverage Limit is $39.

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$169

Monthly Premium

Medicare Plan Features
Monthly Premium: $169.00
Part C Premium: $130.0
Monthly Premium: Part C Premium: Part D Drug Premium: Part D Supplemental Premium: Total Part D Premium: Drug Deductible: Tiers with No Deductible:
$169.00 $130.0 $39.00 $0 $39.00 $0 0.0
Gap Coverage: Yes
Benchmark: not below the regional benchmark
Type of Medicare Health: Enhanced Alternative
Health Plan Type: Local PPO
Similar Plan: H5521-123
Special Needs Type: NULL
Chronic Condition: NULL
Additional Gap Coverage: Yes, some additional gap coverage.
Maximum Out-of-Pocket Limit for Parts A & B (Moop): $7,550
Annual Deductible: NULL
Annual Initial Coverage Limit ICL: $4,130
Number of Members enrolled in this plan in Forest, Pennsylvania: Plans Summary Star Rating: Customer Service Rating: Drug Cost Rating:
less than 10 members 4 out of 5 Stars. 5 out of 5 Stars. 3 out of 5 Stars.
Plan Offers Mail Order: Yes
Plan Health Benefits
Total # of Formulary Drugs: 3,780 drugs
Number of Members Enrolled in this Plan in Forest, Pennsylvania: 2,287 members
Number of Drugs Per Tier: NULL
Preferred Pharmacy Cost Sharing During Initial Coverage Phase: NULL
Special Needs Plan SNP Eligibility Requirement: NULL
Monthly Premium Split as Follows:
Part C Premium Part D Base Premium Part D Supplemental Premium Total Premium
$130.00 $39.00 $0.00 $169.00
Monthly Premium with Extra Help Low Income Subsidy:
LIS100 Subsidy Total Monthly Premium with LIS Parts CD LIS25 Subsidy Monthly PartD Premium with LIS LIS25 Subsidy Total Monthly Premium with LIS Parts CD LIS50 Monthly PartD Premium with LIS LIS50 Subsidy Total Monthly Premium with LIS Parts CD LIS75 Monthly PartD Premium with LIS LIS75 Subsidy Total Monthly Premium with LIS Parts CD
$131.50 $29.60 $159.60 $20.30 $150.30 $10.90 $140.90
Formulary Drug Details:
Tier 1 # of Drugs per Tier Tier 1 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 2 # of Drugs per Tier Tier 2 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 3 # of Drugs per Tier Tier 3 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 4 # of Drugs per Tier Tier 4 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 5 # of Drugs per Tier Tier 6 Preferred Pharmacy Cost Sharing (initial coverage phase)
337 $2.00 571 $5.00 915 $47.00 1247 $100.00 710 33%

Other Medicare Advantage Plans in Forest, Pennsylvania

Plan Name Type Premium MOOP Rx Deduct. Rating
HumanaChoice H5525-038 (PPO) (2023)Local PPO$6,700$0
4
HumanaChoice R0923-001 (Regional PPO) (2023)Regional PPO *$4,900$-
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HumanaChoice R0923-002 (Regional PPO) (2023)Regional PPO$6,700$0
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Aetna Medicare Advantra Silver (PPO) (2023)Local PPO$7,550$0
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Humana Value Plus H5525-039 (PPO) (2023)Local PPO$6,700$400
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UPMC for Life PPO High Deductible with Rx (PPO) (2023)Local PPO$7,550$0
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UPMC for Life PPO Rx Enhanced (PPO) (2023)Local PPO$7,550$0
3
Humana Honor (PPO) (2023)Local PPO *$6,700$-
4
Security Blue HMO-POS Deluxe (HMO-POS) (2023)Local HMO$4,500$0
4
Community Blue Medicare HMO Signature (HMO) (2023)Local HMO$7,550$0
4
Aetna Medicare Value (PPO) (2023)Local PPO$7,550$0
5
HumanaChoice H5216-116 (PPO) (2023)Local PPO *$3,900$-
4
Aetna Medicare Advantra Gold (HMO) (2023)Local HMO$4,900$0
5
Aetna Medicare Advantra Silver (HMO) (2023)Local HMO$7,550$0
5
Aetna Medicare Advantra Premier (HMO) (2023)Local HMO$5,900$0
5
Security Blue HMO-POS Basic (HMO-POS) (2023)Local HMO *$5,900$-
4
Freedom Blue PPO ValueRx (PPO) (2023)Local PPO$5,500$0
4
Allwell Medicare Complement (HMO) (2023)Local HMO$7,550$445
4
Freedom Blue PPO Classic (PPO) (2023)Local PPO$4,500$0
4
Security Blue HMO-POS ValueRx (HMO-POS) (2023)Local HMO$5,500$0
4
Security Blue HMO-POS Standard (HMO-POS) (2023)Local HMO$5,000$0
4
AARP Medicare Advantage Patriot (HMO) (2023)Local HMO *$5,500$-
5
UPMC for Life HMO Rx (HMO) (2023)Local HMO$7,550$0
4
Aetna Medicare Advantra Eagle (HMO) (2023)Local HMO *$4,000$-
5
Lasso Healthcare Growth (MSA) (2023)MSA *$-$-
4
Complete Blue PPO Distinct (PPO) (2023)Local PPO$6,500$0
4
Allwell Medicare Boost (HMO) (2023)Local HMO$7,550$0
4
AARP Medicare Advantage Choice (PPO) (2023)Local PPO$4,900$0
New plan - not yet rated.
Lasso Healthcare Growth Plus (MSA) (2023)MSA *$-$-
4
UPMC for Life HMO Deductible with Rx (HMO) (2023)Local HMO$7,550$0
4
Allwell Medicare (HMO) (2023)Local HMO$6,700$0
4
Community Blue Medicare PPO Signature (PPO) (2023)Local PPO$6,500$0
4
Aetna Medicare Silver (HMO) (2023)Local HMO$7,550$0
5
Allwell Medicare Simple (HMO) (2023)Local HMO *$3,450$-
4
UPMC for Life HMO No Rx (HMO) (2023)Local HMO *$7,550$-
4
AARP Medicare Advantage Plan 1 (HMO) (2023)Local HMO$6,700$0
5
UPMC for Life HMO Rx Enhanced (HMO) (2023)Local HMO$7,550$0
4
UPMC for Life HMO Rx Choice (HMO) (2023)Local HMO$7,550$0
4
Freedom Blue PPO Select (PPO) (2023)Local PPO$5,000$0
4
AARP Medicare Advantage Plan 2 (HMO) (2023)Local HMO$5,500$0
5
Medicare Advantage Plans by Aetna Medicare
Aetna Medicare Advantra Silver (PPO) (2023)Local PPO$7,550$0
5
Aetna Medicare Value (PPO) (2023)Local PPO$7,550$0
5
Aetna Medicare Advantra Gold (HMO) (2023)Local HMO$4,900$0
5
Aetna Medicare Advantra Silver (HMO) (2023)Local HMO$7,550$0
5
Aetna Medicare Advantra Premier (HMO) (2023)Local HMO$5,900$0
5
Aetna Medicare Advantra Eagle (HMO) (2023)Local HMO *$4,000$-
5
Aetna Medicare Silver (HMO) (2023)Local HMO$7,550$0
5

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