Aetna Signature Extra PPO
EyeMed link: AetnaMedicareVision.com
Nations Hearing Link: Aetna.Nationsbenefits.com/Hearing
Dental link: https://shorturl.at/RoEcQ
Find a Doc: Aetnamedicare.com/en/find-doctors-hospitals/find-provider.html
For a complete listing of benefits for 2026, visit http://AetnaMedicare.com/h5521-403
Aetna Customer Service: 1-833-570-6670
2026
2027
Signature Extra PPO
(H5521-403)
Signature Extra PPO
(H5521-403)
In Network / Out of Network
In Network / Out of Network
Premium
$0
$0
Primary Doctor
$0 / 50%
$0 / 50%
Specialist
$40 / 50%
$45 / 50%
Physical Therapy
$45 / 50%
$45 / 50%
Urgent Care
$35
$50
Hospital
$355 days 1-8
$355 days 1-7
Maximum Out Of Pocket
$5,500 / $10,100 for in- and out-of-network services combined
$5,500 / $10,750 for in- and out-of-network services combined
Outpatient Surgery
$355 / 50%
$355 / 50%
Ambulance
$275 / 20% AIR
$275 / 20% AIR
Emergency
$130
$130
Lab Services
$0 / 50%
$0 / 50%
X-Rays
$15 / 50%
$15 / 50%
Complex Diagnostic
$275 / 50%
$275 / 50%
Part D (Tiers 1-4)
$0 / $0/ 24% / 25%
$0 / $5 / 17% / 28%
100 Day- Mail Order
$0 / $0 / 24% / 25%
$0 / $5 / 17% / 28%
Part D Deductible
$615
(applies to tiers 3, 4, 5)
$500
(applies to tiers 3, 4, 5)
Gym Membership
Silver Sneakers
Silver Sneakers
Dental
$2,000 Benefit
$1,500 Benefit
Dental Network
Aetna Dental PPO Network
Aetna Dental PPO Network
Vision
$150 (Eye Med)
$100 (Eye Med)
Extras
$90 per Quarter for fitness reimbursement
$90 per Quarter for fitness reimbursement
For a full listing of benefits, please request the Summary of Benefits via email, info@fhkinsurance.com
Aetna Signature Extra PPO
2026
2027
Signature Extra PPO
H5521-403
Signature Extra PPO
H5521-403
In Network / Out of Network
In Network / Out of Network
Premium
$0
$0
Primary Doctor
$0 / 50%
$0 / 50%
Specialist
$40 / 50%
$45 / 50%
Physical Therapy
$45 / 50%
$45 / 50%
Urgent Care
$35
$50
Hospital
$355 days 1-8
$355 days 1-7
MOOP Cap
$5,500 / $10,100 for in- and out-of-network services combined
$5,500 / $10,100 for in- and out-of-network services combined
Outpatient Surgery
$355 / 50%
$355 / 50%
Ambulance
$275 / 20% (air)
$275 / 20% (air)
Emergency
$130
$130
Lab Services
$0 / 50%
$0 / 50%
X-Rays
$15 / 50%
$15 / 50%
Complex Diagnostic
$275 / 50%
$275 / 50%
Part D (Tiers 1-4)
$0 / $0 / 24% / 25%
$0 / $5 / 17% / 28%
100 Day- Mail Order
$0 / $0 / 24% / 25%
$0 / $5 / 17% / 28%
Part D Deductible
$615
(applies to 3,4,5)
$500
(applies to 3,4,5)
Hearing Aid
$500 Allowance per ear
$500 Allowance per ear
OTC
N/A
N/A
Gym Membership
Silver Sneakers
Silver Sneakers
Dental
$2000 Benefit
$0 Copay for preventive services
20%-30% coinsurance for comprehensive services
$1500 Benefit
$0 Copay for preventive services
20%-30% coinsurance for comprehensive services
Dental Network
Aetna Dental PPO Network / 50%-70% coinsurance for preventive and comprehensive services for out-of-network services
Aetna Dental PPO Network / 50%-70% coinsurance for preventive and comprehensive services for out-of-network services
Vision
$150 (Eye Med)
$100 (Eye Med)
Extras
$90 per Quarter for fitness reimbursement
$90 per Quarter for fitness reimbursement
For a full listing of benefits, please request the Summary of Benefits via email, info@fhkinsurance.com
EyeMed link: AetnaMedicareVision.com
Nations Hearing Link: Aetna.Nationsbenefits.com/Hearing
Dental link: https://shorturl.at/RoEcQ
Find a Doc: Aetnamedicare.com/en/find-doctors-hospitals/find-provider.html
For a complete listing of benefits for 2026, visit http://AetnaMedicare.com/h5521-403
Aetna Customer Service: 1-833-570-6670