Aetna Medicare Choices
Low Income Subsidy
Aetna Medicare Plan (PPO) —
2010 Monthly Plan Premium for People who get Extra Help from Medicare to Help Pay for Their Prescription Drug Costs
If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan.
If you aren’t getting extra help, you can see if you qualify by calling:
- 1-800-Medicare (TTY/TDD users call 1-877-486-2048) - 24 hours a day/7 days a week,
- Your State Medicaid Office, or
- The Social Security Administration at 1-800-772-1213. TTY/TDD users should call 1-800-325-0778 between 7 a.m. and 7 p.m., Monday through Friday.
If you have any questions, please call our representatives at 1-800-529-5586 (TTY/TDD: 1-888-760-4748), Monday to Sunday, 8 a.m. to 8 p.m.
The table below tells how much you will pay for a monthly premium if you receive extra help. (This does not include any Medicare Part B premium you may have to pay.)
| Your State and County |
Aetna Medicare (PPO) Plan Name |
Premium Without Extra Help |
Aetna Medicare Premium for Your Level of Extra Help | |||
| 100% | 75% | 50% | 25% | |||
| Colorado | ||||||
| Adams | Standard Plan | $55.00 | $33.00 | $38.50 | $44.00 | $49.50 |
| Premier Plan | $110.00 | $87.70 | $93.30 | $98.80 | $104.40 | |
| Arapahoe | Standard Plan | $55.00 | $33.00 | $38.50 | $44.00 | $49.50 |
| Premier Plan | $110.00 | $87.70 | $93.30 | $98.80 | $104.40 | |
| Boulder | Standard Plan | $55.00 | $33.00 | $38.50 | $44.00 | $49.50 |
| Premier Plan | $110.00 | $87.70 | $93.30 | $98.80 | $104.40 | |
| Broomfield | Standard Plan | $55.00 | $33.00 | $38.50 | $44.00 | $49.50 |
| Premier Plan | $110.00 | $87.70 | $93.30 | $98.80 | $104.40 | |
| Denver | Standard Plan | $55.00 | $33.00 | $38.50 | $44.00 | $49.50 |
| Premier Plan | $110.00 | $87.70 | $93.30 | $98.80 | $104.40 | |
| Douglas | Standard Plan | $55.00 | $33.00 | $38.50 | $44.00 | $49.50 |
| Premier Plan | $110.00 | $87.70 | $93.30 | $98.80 | $104.40 | |
| Jefferson | Standard Plan | $55.00 | $33.00 | $38.50 | $44.00 | $49.50 |
| Premier Plan | $110.00 | $87.70 | $93.30 | $98.80 | $104.40 | |
| Connecticut | ||||||
| Fairfield | Standard Plan | $82.00 | $48.80 | $57.10 | $65.40 | $73.70 |
| Premier Plan | $143.00 | $108.40 | $117.10 | $125.70 | $134.40 | |
| Hartford | Standard Plan | $82.00 | $48.80 | $57.10 | $65.40 | $73.70 |
| Premier Plan | $143.00 | $108.40 | $117.10 | $125.70 | $134.40 | |
| Litchfield | Standard Plan | $82.00 | $48.80 | $57.10 | $65.40 | $73.70 |
| Premier Plan | $143.00 | $108.40 | $117.10 | $125.70 | $134.40 | |
| New Haven | Standard Plan | $82.00 | $48.80 | $57.10 | $65.40 | $73.70 |
| Premier Plan | $143.00 | $108.40 | $117.10 | $125.70 | $134.40 | |
| Delaware | ||||||
| New Castle | Premier Plan | $171.50 | $152.50 | $157.20 | $162.00 | $166.70 |
| District of Columbia | ||||||
| District of Columbia | Premier Plan | $169.00 | $146.00 | $151.70 | $157.50 | $163.20 |
| Florida | ||||||
| Broward | Standard Plan | $123.00 | $95.50 | $102.40 | $109.30 | $116.10 |
| Premier Plan | $158.00 | $132.30 | $138.70 | $145.10 | $151.60 | |
| Charlotte | Standard Plan | $108.00 | $80.50 | $87.40 | $94.30 | $101.10 |
| Premier Plan | $143.00 | $117.20 | $123.60 | $130.10 | $136.50 | |
| Duval | Standard Plan | $108.00 | $82.30 | $88.70 | $95.10 | $101.60 |
| Premier Plan | $143.00 | $126.50 | $130.60 | $134.70 | $138.90 | |
| Hernando | Standard Plan | $108.00 | $80.50 | $87.40 | $94.30 | $101.10 |
| Premier Plan | $143.00 | $117.20 | $123.60 | $130.10 | $136.50 | |
| Hillsborough | Standard Plan | $108.00 | $80.50 | $87.40 | $94.30 | $101.10 |
| Premier Plan | $143.00 | $117.20 | $123.60 | $130.10 | $136.50 | |
| Lee | Standard Plan | $108.00 | $80.50 | $87.40 | $94.30 | $101.10 |
| Premier Plan | $143.00 | $117.20 | $123.60 | $130.10 | $136.50 | |
| Manatee | Standard Plan | $108.00 | $80.50 | $87.40 | $94.30 | $101.10 |
| Premier Plan | $143.00 | $117.20 | $123.60 | $130.10 | $136.50 | |
| Miami-Dade | Standard Plan | $123.00 | $95.50 | $102.40 | $109.30 | $116.10 |
| Premier Plan | $158.00 | $132.30 | $138.70 | $145.10 | $151.60 | |
| Palm Beach | Standard Plan | $123.00 | $95.50 | $102.40 | $109.30 | $116.10 |
| Premier Plan | $158.00 | $132.30 | $138.70 | $145.10 | $151.60 | |
| Pasco | Standard Plan | $108.00 | $80.50 | $87.40 | $94.30 | $101.10 |
| Premier Plan | $143.00 | $117.20 | $123.60 | $130.10 | $136.50 | |
| Pinellas | Standard Plan | $108.00 | $80.50 | $87.40 | $94.30 | $101.10 |
| Premier Plan | $143.00 | $117.20 | $123.60 | $130.10 | $136.50 | |
| Polk | Standard Plan | $108.00 | $80.50 | $87.40 | $94.30 | $101.10 |
| Premier Plan | $143.00 | $117.20 | $123.60 | $130.10 | $136.50 | |
| Saint Johns | Standard Plan | $108.00 | $82.30 | $88.70 | $95.10 | $101.60 |
| Premier Plan | $143.00 | $126.50 | $130.60 | $134.70 | $138.90 | |
| Sarasota | Standard Plan | $108.00 | $80.50 | $87.40 | $94.30 | $101.10 |
| Premier Plan | $143.00 | $117.20 | $123.60 | $130.10 | $136.50 | |
| Georgia | ||||||
| DeKalb | Standard Plan | $68.00 | $50.10 | $54.60 | $59.00 | $63.50 |
| Premier Plan | $123.00 | $97.70 | $104.00 | $110.30 | $116.70 | |
| Forsyth | Standard Plan | $68.00 | $50.10 | $54.60 | $59.00 | $63.50 |
| Premier Plan | $123.00 | $97.70 | $104.00 | $110.30 | $116.70 | |
| Fulton | Standard Plan | $68.00 | $50.10 | $54.60 | $59.00 | $63.50 |
| Premier Plan | $123.00 | $97.70 | $104.00 | $110.30 | $116.70 | |
| Gwinett | Standard Plan | $68.00 | $50.10 | $54.60 | $59.00 | $63.50 |
| Premier Plan | $123.00 | $97.70 | $104.00 | $110.30 | $116.70 | |
| Illinois | ||||||
| Cook | Standard Plan | $86.00 | $60.30 | $66.70 | $73.10 | $79.60 |
| Premier Plan | $149.00 | $137.00 | $140.00 | $143.00 | $146.00 | |
| Maine | ||||||
| Cumberland | Standard Plan | $64.00 | $55.30 | $57.50 | $59.60 | $61.80 |
| York | Standard Plan | $64.00 | $55.30 | $57.50 | $59.60 | $61.80 |
| Maryland | ||||||
| Anne Arundel | Standard Plan | $140.00 | $122.20 | $126.60 | $131.10 | $135.50 |
| Premier Plan | $199.00 | $165.30 | $173.70 | $182.10 | $190.60 | |
| Baltimore | Standard Plan | $140.00 | $122.20 | $126.60 | $131.10 | $135.50 |
| Premier Plan | $199.00 | $165.30 | $173.70 | $182.10 | $190.60 | |
| Baltimore City | Standard Plan | $140.00 | $122.20 | $126.60 | $131.10 | $135.50 |
| Premier Plan | $199.00 | $165.30 | $173.70 | $182.10 | $190.60 | |
| Calvert | Standard Plan | $140.00 | $122.20 | $126.60 | $131.10 | $135.50 |
| Premier Plan | $199.00 | $165.30 | $173.70 | $182.10 | $190.60 | |
| Carroll | Standard Plan | $140.00 | $122.20 | $126.60 | $131.10 | $135.50 |
| Premier Plan | $199.00 | $165.30 | $173.70 | $182.10 | $190.60 | |
| Cecil | Standard Plan | $140.00 | $122.20 | $126.60 | $131.10 | $135.50 |
| Premier Plan | $199.00 | $165.30 | $173.70 | $182.10 | $190.60 | |
| Charles | Standard Plan | $140.00 | $122.20 | $126.60 | $131.10 | $135.50 |
| Premier Plan | $199.00 | $165.30 | $173.70 | $182.10 | $190.60 | |
| Frederick | Standard Plan | $140.00 | $122.20 | $126.60 | $131.10 | $135.50 |
| Premier Plan | $199.00 | $165.30 | $173.70 | $182.10 | $190.60 | |
| Harford | Standard Plan | $140.00 | $122.20 | $126.60 | $131.10 | $135.50 |
| Premier Plan | $199.00 | $165.30 | $173.70 | $182.10 | $190.60 | |
| Howard | Standard Plan | $140.00 | $122.20 | $126.60 | $131.10 | $135.50 |
| Premier Plan | $199.00 | $165.30 | $173.70 | $182.10 | $190.60 | |
| Montgomery | Standard Plan | $140.00 | $122.20 | $126.60 | $131.10 | $135.50 |
| Premier Plan | $199.00 | $165.30 | $173.70 | $182.10 | $190.60 | |
| Prince Georges | Standard Plan | $140.00 | $122.20 | $126.60 | $131.10 | $135.50 |
| Premier Plan | $199.00 | $165.30 | $173.70 | $182.10 | $190.60 | |
| Nevada | ||||||
| Clark | Select Plan | $58.00 | $30.70 | $37.50 | $44.30 | $51.20 |
| New Jersey | ||||||
| Essex | Standard Plan | $108.00 | $73.00 | $81.70 | $90.50 | $99.20 |
| Premier Plan | $158.00 | $123.00 | $131.70 | $140.50 | $149.20 | |
| Hudson | Standard Plan | $108.00 | $73.00 | $81.70 | $90.50 | $99.20 |
| Premier Plan | $158.00 | $123.00 | $131.70 | $140.50 | $149.20 | |
| Middlesex | Standard Plan | $108.00 | $73.00 | $81.70 | $90.50 | $99.20 |
| Premier Plan | $158.00 | $123.00 | $131.70 | $140.50 | $149.20 | |
| Morris | Standard Plan | $108.00 | $73.00 | $81.70 | $90.50 | $99.20 |
| Premier Plan | $158.00 | $123.00 | $131.70 | $140.50 | $149.20 | |
| Ocean | Standard Plan | $108.00 | $73.00 | $81.70 | $90.50 | $99.20 |
| Premier Plan | $158.00 | $123.00 | $131.70 | $140.50 | $149.20 | |
| Passaic | Standard Plan | $108.00 | $73.00 | $81.70 | $90.50 | $99.20 |
| Premier Plan | $158.00 | $123.00 | $131.70 | $140.50 | $149.20 | |
| New York | ||||||
| Broome | Standard Plan | $47.00 | $14.70 | $22.80 | $30.80 | $38.90 |
| Cayuga | Standard Plan | $47.00 | $14.70 | $22.80 | $30.80 | $38.90 |
| Nassau | Standard Plan | $119.00 | $95.70 | $101.50 | $107.30 | $113.20 |
| Premier Plan | $154.00 | $120.70 | $129.00 | $137.30 | $145.70 | |
| New York | Standard Plan | $86.00 | $61.50 | $67.60 | $73.70 | $79.90 |
| Premier Plan | $145.00 | $111.70 | $120.00 | $128.30 | $136.70 | |
| Onondaga | Standard Plan | $47.00 | $14.70 | $22.80 | $30.80 | $38.90 |
| Oswego | Standard Plan | $47.00 | $14.70 | $22.80 | $30.80 | $38.90 |
| Queens | Standard Plan | $86.00 | $61.50 | $67.60 | $73.70 | $79.90 |
| Premier Plan | $145.00 | $111.70 | $120.00 | $128.30 | $136.70 | |
| Richmond | Standard Plan | $86.00 | $61.50 | $67.60 | $73.70 | $79.90 |
| Premier Plan | $145.00 | $111.70 | $120.00 | $128.30 | $136.70 | |
| Suffolk | Standard Plan | $119.00 | $95.70 | $101.50 | $107.30 | $113.20 |
| Premier Plan | $154.00 | $120.70 | $129.00 | $137.30 | $145.70 | |
| Tioga | Standard Plan | $47.00 | $14.70 | $22.80 | $30.80 | $38.90 |
| Ohio | ||||||
| Cuyahoga | Standard Plan | $65.00 | $56.00 | $58.20 | $60.50 | $62.70 |
| Delaware | Standard Plan | $103.00 | $85.80 | $90.10 | $94.40 | $98.70 |
| Franklin | Standard Plan | $103.00 | $85.80 | $90.10 | $94.40 | $98.70 |
| Hamilton | Standard Plan | $103.00 | $85.80 | $90.10 | $94.40 | $98.70 |
| Lucas | Standard Plan | $103.00 | $85.80 | $90.10 | $94.40 | $98.70 |
| Summit | Standard Plan | $65.00 | $56.00 | $58.20 | $60.50 | $62.70 |
| Pennsylvania | ||||||
| Berks | Standard Plan | $115.00 | $97.90 | $102.20 | $106.40 | $110.70 |
| Premier Plan | $140.00 | $123.50 | $127.60 | $131.70 | $135.90 | |
| Carbon | Standard Plan | $115.00 | $97.90 | $102.20 | $106.40 | $110.70 |
| Premier Plan | $140.00 | $123.50 | $127.60 | $131.70 | $135.90 | |
| Lancaster | Standard Plan | $115.00 | $97.90 | $102.20 | $106.40 | $110.70 |
| Premier Plan | $140.00 | $123.50 | $127.60 | $131.70 | $135.90 | |
| Lebanon | Standard Plan | $115.00 | $97.90 | $102.20 | $106.40 | $110.70 |
| Premier Plan | $140.00 | $123.50 | $127.60 | $131.70 | $135.90 | |
| Lehigh | Standard Plan | $115.00 | $97.90 | $102.20 | $106.40 | $110.70 |
| Premier Plan | $140.00 | $123.50 | $127.60 | $131.70 | $135.90 | |
| Monroe | Standard Plan | $115.00 | $97.90 | $102.20 | $106.40 | $110.70 |
| Premier Plan | $140.00 | $123.50 | $127.60 | $131.70 | $135.90 | |
| Northampton | Standard Plan | $115.00 | $97.90 | $102.20 | $106.40 | $110.70 |
| Premier Plan | $140.00 | $123.50 | $127.60 | $131.70 | $135.90 | |
| Schuylkill | Standard Plan | $115.00 | $97.90 | $102.20 | $106.40 | $110.70 |
| Premier Plan | $140.00 | $123.50 | $127.60 | $131.70 | $135.90 | |
| Texas | ||||||
| Bexar | Value Plan | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Premier Plan | $50.00 | $22.50 | $29.40 | $36.20 | $43.10 | |
| Comal | Value Plan | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Premier Plan | $50.00 | $22.50 | $29.40 | $36.20 | $43.10 | |
| Collin | Value Plan | $50.00 | $34.60 | $38.40 | $42.30 | $46.10 |
| Premier Plan | $100.00 | $72.50 | $79.40 | $86.20 | $93.10 | |
| Dallas | Value Plan | $50.00 | $34.60 | $38.40 | $42.30 | $46.10 |
| Premier Plan | $100.00 | $72.50 | $79.40 | $86.20 | $93.10 | |
| Denton | Value Plan | $50.00 | $34.60 | $38.40 | $42.30 | $46.10 |
| Premier Plan | $100.00 | $72.50 | $79.40 | $86.20 | $93.10 | |
| Harris | Value Plan | $35.00 | $23.30 | $26.20 | $29.10 | $32.10 |
| Premier Plan | $60.00 | $32.50 | $39.40 | $46.20 | $53.10 | |
| Montgomery | Value Plan | $35.00 | $23.30 | $26.20 | $29.10 | $32.10 |
| Premier Plan | $60.00 | $32.50 | $39.40 | $46.20 | $53.10 | |
| Tarrant | Value Plan | $50.00 | $34.60 | $38.40 | $42.30 | $46.10 |
| Premier Plan | $100.00 | $72.50 | $79.40 | $86.20 | $93.10 | |
| Virginia | ||||||
| Alexandria City | Standard Plan | $133.00 | $98.80 | $107.40 | $115.90 | $124.50 |
| Premier Plan | $197.00 | $162.80 | $171.40 | $179.90 | $188.50 | |
| Arlington | Standard Plan | $133.00 | $98.80 | $107.40 | $115.90 | $124.50 |
| Premier Plan | $197.00 | $162.80 | $171.40 | $179.90 | $188.50 | |
| Fairfax | Standard Plan | $133.00 | $98.80 | $107.40 | $115.90 | $124.50 |
| Premier Plan | $197.00 | $162.80 | $171.40 | $179.90 | $188.50 | |
| Fairfax City | Standard Plan | $133.00 | $98.80 | $107.40 | $115.90 | $124.50 |
| Premier Plan | $197.00 | $162.80 | $171.40 | $179.90 | $188.50 | |
| Falls Church City | Standard Plan | $133.00 | $98.80 | $107.40 | $115.90 | $124.50 |
| Premier Plan | $197.00 | $162.80 | $171.40 | $179.90 | $188.50 | |
| Loudoun | Standard Plan | $133.00 | $98.80 | $107.40 | $115.90 | $124.50 |
| Premier Plan | $197.00 | $162.80 | $171.40 | $179.90 | $188.50 | |
| Manassas City | Standard Plan | $133.00 | $98.80 | $107.40 | $115.90 | $124.50 |
| Premier Plan | $197.00 | $162.80 | $171.40 | $179.90 | $188.50 | |
| Manassas Park City | Standard Plan | $133.00 | $98.80 | $107.40 | $115.90 | $124.50 |
| Premier Plan | $197.00 | $162.80 | $171.40 | $179.90 | $188.50 | |
| Prince William | Standard Plan | $133.00 | $98.80 | $107.40 | $115.90 | $124.50 |
| Premier Plan | $197.00 | $162.80 | $171.40 | $179.90 | $188.50 | |
For the Aetna Medicare Plan (PPO): Higher costs apply for out-of-network services. Precertification, or prior approval of coverage, is requested for certain services. Providers must be licensed and eligible to receive payment under the federal Medicare program.
Coverage is provided through a Medicare Advantage organization or a Medicare prescription drug plan sponsor with a Medicare contract. Benefits, limitations, service areas and premiums are subject to change on January 1 of each year.
