Aetna Medicare Choices
Low Income Subsidy
Aetna Medicare Plan (PPO) —
2013 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 (1-800-633-4227) or 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 1-888-247-1028, 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.) The Aetna Medicare Plan (PPO) premium includes coverage for both medical services and prescription drug coverage.
| 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 | Select Plan | $68.00 | $36.10 | $44.10 | $52.00 | $60.00 |
| Arapahoe | Select Plan | $68.00 | $36.10 | $44.10 | $52.00 | $60.00 |
| Boulder | Select Plan | $68.00 | $36.10 | $44.10 | $52.00 | $60.00 |
| Broomfield | Select Plan | $68.00 | $36.10 | $44.10 | $52.00 | $60.00 |
| Denver | Select Plan | $68.00 | $36.10 | $44.10 | $52.00 | $60.00 |
| Douglas | Select Plan | $68.00 | $36.10 | $44.10 | $52.00 | $60.00 |
| Jefferson | Select Plan | $68.00 | $36.10 | $44.10 | $52.00 | $60.00 |
| Connecticut | ||||||
| Fairfield | Standard Plan | $90.00 | $58.60 | $66.50 | $74.30 | $82.20 |
| Hartford | Standard Plan | $90.00 | $58.60 | $66.50 | $74.30 | $82.20 |
| Litchfield | Standard Plan | $90.00 | $58.60 | $66.50 | $74.30 | $82.20 |
| New Haven | Standard Plan | $90.00 | $58.60 | $66.50 | $74.30 | $82.20 |
| Delaware | ||||||
| New Castle | Premier Plan | $169.00 | $134.00 | $142.80 | $151.50 | $160.30 |
| District of Columbia | ||||||
| District of Columbia | Premier Plan | $83.00 | $48.00 | $56.80 | $65.50 | $74.30 |
| Florida | ||||||
| Broward | Premier Plan | $33.00 | $8.20 | $14.40 | $20.60 | $26.80 |
| Charlotte | Premier Plan | $33.00 | $8.20 | $14.40 | $20.60 | $26.80 |
| Duval | Premier Plan | $33.00 | $8.20 | $14.40 | $20.60 | $26.80 |
| Hillsborough | Premier Plan | $33.00 | $8.20 | $14.40 | $20.60 | $26.80 |
| Lee | Premier Plan | $33.00 | $8.20 | $14.40 | $20.60 | $26.80 |
| Manatee | Premier Plan | $33.00 | $8.20 | $14.40 | $20.60 | $26.80 |
| Miami-Dade | Premier Plan | $33.00 | $8.20 | $14.40 | $20.60 | $26.80 |
| Palm Beach | Premier Plan | $33.00 | $8.20 | $14.40 | $20.60 | $26.80 |
| Pasco | Premier Plan | $33.00 | $8.20 | $14.40 | $20.60 | $26.80 |
| Pinellas | Premier Plan | $33.00 | $8.20 | $14.40 | $20.60 | $26.80 |
| Saint Johns | Premier Plan | $33.00 | $8.20 | $14.40 | $20.60 | $26.80 |
| Sarasota | Premier Plan | $33.00 | $8.20 | $14.40 | $20.60 | $26.80 |
| Georgia | ||||||
| DeKalb | Standard Plan | $45.00 | $10.80 | $19.30 | $27.90 | $36.40 |
| Forsyth | Standard Plan | $45.00 | $10.80 | $19.30 | $27.90 | $36.40 |
| Fulton | Standard Plan | $45.00 | $10.80 | $19.30 | $27.90 | $36.40 |
| Gwinett | Standard Plan | $45.00 | $10.80 | $19.30 | $27.90 | $36.40 |
| Illinois | ||||||
| Cook | Standard Plan | $82.00 | $51.10 | $58.80 | $66.50 | $74.30 |
| Maryland | ||||||
| Anne Arundel | Standard Plan | $93.00 | $58.00 | $66.80 | $75.50 | $84.30 |
| Baltimore | Standard Plan | $93.00 | $58.00 | $66.80 | $75.50 | $84.30 |
| Baltimore City | Standard Plan | $93.00 | $58.00 | $66.80 | $75.50 | $84.30 |
| Calvert | Standard Plan | $93.00 | $58.00 | $66.80 | $75.50 | $84.30 |
| Carroll | Standard Plan | $93.00 | $58.00 | $66.80 | $75.50 | $84.30 |
| Cecil | Standard Plan | $93.00 | $58.00 | $66.80 | $75.50 | $84.30 |
| Charles | Standard Plan | $93.00 | $58.00 | $66.80 | $75.50 | $84.30 |
| Frederick | Standard Plan | $93.00 | $58.00 | $66.80 | $75.50 | $84.30 |
| Harford | Standard Plan | $93.00 | $58.00 | $66.80 | $75.50 | $84.30 |
| Howard | Standard Plan | $93.00 | $58.00 | $66.80 | $75.50 | $84.30 |
| Montgomery | Standard Plan | $93.00 | $58.00 | $66.80 | $75.50 | $84.30 |
| Prince Georges | Standard Plan | $93.00 | $58.00 | $66.80 | $75.50 | $84.30 |
| Nevada | ||||||
| Clark | Select Plan | $69.00 | $59.80 | $62.10 | $64.40 | $66.70 |
| New Jersey | ||||||
| Essex | Premier Plan | $159.00 | $122.00 | $131.20 | $140.50 | $149.70 |
| Standard Plan | $68.00 | $32.20 | $41.10 | $50.10 | $59.00 | |
| Hudson | Premier Plan | $159.00 | $122.00 | $131.20 | $140.50 | $149.70 |
| Standard Plan | $68.00 | $32.20 | $41.10 | $50.10 | $59.00 | |
| Middlesex | Premier Plan | $159.00 | $122.00 | $131.20 | $140.50 | $149.70 |
| Standard Plan | $68.00 | $32.20 | $41.10 | $50.10 | $59.00 | |
| Morris | Premier Plan | $159.00 | $122.00 | $131.20 | $140.50 | $149.70 |
| Standard Plan | $68.00 | $32.20 | $41.10 | $50.10 | $59.00 | |
| Ocean | Premier Plan | $159.00 | $122.00 | $131.20 | $140.50 | $149.70 |
| Standard Plan | $68.00 | $32.20 | $41.10 | $50.10 | $59.00 | |
| Passaic | Premier Plan | $159.00 | $122.00 | $131.20 | $140.50 | $149.70 |
| Standard Plan | $68.00 | $32.20 | $41.10 | $50.10 | $59.00 | |
| New York | ||||||
| Broome | Standard Plan | $85.00 | $46.20 | $55.90 | $65.60 | $75.30 |
| Cayuga | Standard Plan | $85.00 | $46.20 | $55.90 | $65.60 | $75.30 |
| New York | Standard Plan | $85.00 | $46.20 | $55.90 | $65.60 | $75.30 |
| Onondaga | Standard Plan | $85.00 | $46.20 | $55.90 | $65.60 | $75.30 |
| Oswego | Standard Plan | $85.00 | $46.20 | $55.90 | $65.60 | $75.30 |
| Queens | Standard Plan | $85.00 | $46.20 | $55.90 | $65.60 | $75.30 |
| Richmond | Standard Plan | $85.00 | $46.20 | $55.90 | $65.60 | $75.30 |
| Tioga | Standard Plan | $85.00 | $46.20 | $55.90 | $65.60 | $75.30 |
| Ohio | ||||||
| Cuyahoga | Standard Plan | $69.00 | $39.10 | $46.60 | $54.10 | $61.50 |
| Delaware | Standard Plan | $69.00 | $39.10 | $46.60 | $54.10 | $61.50 |
| Franklin | Standard Plan | $69.00 | $39.10 | $46.60 | $54.10 | $61.50 |
| Hamilton | Standard Plan | $69.00 | $39.10 | $46.60 | $54.10 | $61.50 |
| Lucas | Standard Plan | $69.00 | $39.10 | $46.60 | $54.10 | $61.50 |
| Summit | Standard Plan | $69.00 | $39.10 | $46.60 | $54.10 | $61.50 |
| Pennsylvania | ||||||
| Berks | Premier Plan | $120.00 | $83.50 | $92.60 | $101.70 | $110.90 |
| Carbon | Premier Plan | $120.00 | $83.50 | $92.60 | $101.70 | $110.90 |
| Lancaster | Premier Plan | $120.00 | $83.50 | $92.60 | $101.70 | $110.90 |
| Lebanon | Premier Plan | $120.00 | $83.50 | $92.60 | $101.70 | $110.90 |
| Lehigh | Premier Plan | $120.00 | $83.50 | $92.60 | $101.70 | $110.90 |
| Monroe | Premier Plan | $120.00 | $83.50 | $92.60 | $101.70 | $110.90 |
| Northampton | Premier Plan | $120.00 | $83.50 | $92.60 | $101.70 | $110.90 |
| Schuylkill | Premier Plan | $120.00 | $83.50 | $92.60 | $101.70 | $110.90 |
| Texas | ||||||
| Bexar | Value Plan | $32.00 | $0.20 | $8.10 | $16.10 | $24.00 |
| Collin | Value Plan | $56.00 | $24.20 | $32.10 | $40.10 | $48.00 |
| Comal | Value Plan | $32.00 | $0.20 | $8.10 | $16.10 | $24.00 |
| Dallas | Value Plan | $56.00 | $24.20 | $32.10 | $40.10 | $48.00 |
| Denton | Value Plan | $56.00 | $24.20 | $32.10 | $40.10 | $48.00 |
| Harris | Value Plan | $56.00 | $24.20 | $32.10 | $40.10 | $48.00 |
| Montgomery | Value Plan | $56.00 | $24.20 | $32.10 | $40.10 | $48.00 |
| Tarrant | Value Plan | $56.00 | $24.20 | $32.10 | $40.10 | $48.00 |
| Virginia | ||||||
| Alexandria City | Standard Plan | $58.00 | $27.90 | $35.50 | $43.00 | $50.50 |
| Arlington | Standard Plan | $58.00 | $27.90 | $35.50 | $43.00 | $50.50 |
| Fairfax | Standard Plan | $58.00 | $27.90 | $35.50 | $43.00 | $50.50 |
| Fairfax City | Standard Plan | $58.00 | $27.90 | $35.50 | $43.00 | $50.50 |
| Falls Church City | Standard Plan | $58.00 | $27.90 | $35.50 | $43.00 | $50.50 |
| Loudoun | Standard Plan | $58.00 | $27.90 | $35.50 | $43.00 | $50.50 |
| Manassas City | Standard Plan | $58.00 | $27.90 | $35.50 | $43.00 | $50.50 |
| Manassas Park City | Standard Plan | $58.00 | $27.90 | $35.50 | $43.00 | $50.50 |
| Prince William | Standard Plan | $58.00 | $27.90 | $35.50 | $43.00 | $50.50 |
For the Aetna Medicare Plan (PPO): It may cost more to get care from out-of-network providers, except in an emergency. 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.
Aetna Medicare is a Medicare Advantage organization with a Medicare contract. A Medicare approved Part D sponsor. You must be entitled to Medicare Part A and continue to pay your Part B premium and Part A, if applicable. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1 of each year.
In general, beneficiaries must use network pharmacies to access their prescription drug benefit, except in non-routine circumstances. Pharmacy clinical programs such as prior authorization, step therapy, and quantity limits may apply to your prescription drug coverage.
