Allina Health Aetna Medicare Premier Extra (PPO) Medicare Advantage Plan H3219-004 • 2027 • Wright County, MN
- Monthly Premium
- $169.00Plus Part B premium.
- Medical Deductible
- $0.00
- Maximum Out-of-Pocket
- $3900.00In-network
- Part B Giveback
- Not offered
- Prescription Coverage
- Enhanced, $300.00 deductible
- Additional Benefits
- Dental, Vision, Hearing
- Service Area
- Wright County, MN
- Local Enrollment
- 183 beneficiaries in Wright County
Allina Health Aetna Medicare Premier Extra (PPO) Introduction
This Medicare Advantage PPO plan, Allina Health Aetna Medicare Premier Extra, is offered by Allina Health Aetna Medicare and uses a Preferred Provider Organization (PPO) provider network. It comes with prescription drug coverage. For the 2027 plan year, the monthly premium is $169.00, the medical deductible is $0.00, and the in-network maximum out-of-pocket is $3900.00. The plan is identified by CMS Plan ID H3219-004. The 2027 Part D prescription drug deductible is $300.00.
Enrollment in this plan requires residence in Wright County, Minnesota. CMS enrollment data reports 183 plan members in Wright County. New members can call the plan directly at (844)622-5862 (TTY 711) for assistance.
Compare Similar Plans in Wright County
Compare this plan with the two most-enrolled PPO plans available in Wright County, Minnesota. Enrollment is based on CMS local enrollment data.
| Plan Detail | Allina Health Aetna Medicare Premier Extra | Allina Health Aetna Medicare Enhanced | Allina Health Aetna Medicare Signature |
|---|---|---|---|
| CMS Plan ID | H3219-004-0 |
H3219-002-0 |
H3219-001-0 |
| Local Enrollment | 183 | 1,245 | 871 |
| Monthly Premium | $169.00 | $61.00 | $0.00 |
| Medical Deductible | $0.00 | $0.00 | $0.00 |
| Maximum Out-of-Pocket | $3,900.00 | $5,000.00 | $6,350.00 |
| Part B Giveback | Not offered | Not offered | Not offered |
| Primary Care | $0 copay | $0 copay | $0 copay |
| Specialist | $25 copay | $35 copay | $45 copay |
| Part D Deductible | $300.00 | $300.00 | $400.00 |
| CMS Star Rating | Not yet rated | Not yet rated | Not yet rated |
| Dental | $0 copay | $0 copay | $0 copay |
| Vision | $0 copay | $0 copay | $0 copay |
| Hearing | $0 copay | $0 copay | $0 copay |
Plan Benefits
Cost-sharing for Allina Health Aetna Medicare Premier Extra includes out-of-pocket expenses for covered healthcare services. The following tables provide a summary of typical in-network out-of-pocket costs for plan H3219-004.
You can also compare 2027 costs and coverage with last year, side-by-side: Plan H3219-004-0 Cost Compare.
Office Visits
- Primary care
- In-network: $0 copay
Out-of-network: 50% coinsurance - Specialist
- In-network: $25 copay
Out-of-network: 50% coinsurance
Preventive and Wellness Services
- Annual wellness exam
- In-network: $0 copay
Out-of-network: 50% coinsurance - Telehealth benefit
- In-network: $0-$25 copay, 20% coinsurance
- Routine chiropractic
- In-network: $20 copay
Out-of-network: 50% coinsurance - Fitness benefits
- Coming soon
- Health education
- In-network: $0 copay
Out-of-network: $0 copay - Counseling services
- Not covered
- Over-the-counter drug benefits
- In-network: $0 copay
Out-of-network: $0 copay - Health transportation (non-emergency)
- Coming soon
Diagnostic, Lab, and Imaging Services
- Diagnostic radiology services
- In-network: $0-$150 copay
Out-of-network: 50% coinsurance - Lab services
- In-network: $0 copay
Out-of-network: 50% coinsurance - Outpatient x-rays
- In-network: $15 copay
Out-of-network: 50% coinsurance - Diagnostic tests and procedures
- In-network: $0-$20 copay
Out-of-network: 50% coinsurance
Emergency and Urgent Care Services
- Emergency room care
- $150 copay
- Worldwide emergency care
- Coming soon
- Urgent care
- $25 copay
- Inpatient hospital care
- In-network:
Tier 1
$250 per stay
Out-of-network:
50% per stay - Skilled Nursing Facility
- In-network:
Tier 1
$0 per day for days 1-20
$221 per day for days 21-100
Out-of-network:
50% per stay - Ground ambulance
- In-network: $250 copay
Out-of-network: $250 copay
Mental Health Services
- Outpatient individual therapy
- In-network: $15 copay
Out-of-network: 50% coinsurance - Outpatient group therapy
- In-network: $15 copay
Out-of-network: 50% coinsurance - Inpatient psychiatric hospital care
- In-network:
Tier 1
$250 per stay
Out-of-network:
50% per stay
Rehabilitation Services
- Physical therapy and speech and language therapy
- In-network: $25 copay
Out-of-network: 50% coinsurance - Occupational therapy
- In-network: $25 copay
Out-of-network: 50% coinsurance
Medical Equipment and Supplies
- Diabetes supplies
- In-network: 0%-20% coinsurance
Out-of-network: 0%-20% coinsurance - Durable medical equipment
- In-network: 20% coinsurance
Out-of-network: 50% coinsurance - Prosthetics
- In-network: 20% coinsurance
Out-of-network: 50% coinsurance
Medicare Part B Drugs
- Chemotherapy
- In-network: 0%-20% coinsurance
Out-of-network: 50% coinsurance - Other Part B drugs (Medicare-covered)
- In-network: 0%-20% coinsurance
Out-of-network: 50% coinsurance
Dental Services
- Oral exam
- In-network: $0 copay
Out-of-network: 20% coinsurance - Dental x-rays
- In-network: $0 copay
Out-of-network: 20% coinsurance - Cleaning
- In-network: $0 copay
Out-of-network: 20% coinsurance - Periodontics
- In-network: $0 copay
Out-of-network: 20% coinsurance - Endodontics
- In-network: $0 copay
Out-of-network: 20% coinsurance - Restorative services
- In-network: $0 copay
Out-of-network: 20% coinsurance - Implant services
- Not covered
- Orthodontics
- Not covered
- Oral/Maxillofacial surgery
- In-network: $0 copay
Out-of-network: 20% coinsurance
Vision Services
- Routine eye exam
- In-network: $0 copay
Out-of-network: $0 copay - Contact lenses
- In-network: $0 copay
Out-of-network: $0 copay - Eyeglass frames only
- In-network: $0 copay
Out-of-network: $0 copay - Eyeglass lenses only
- In-network: $0 copay
Out-of-network: $0 copay - Eyeglasses (frames & lenses)
- In-network: $0 copay
Out-of-network: $0 copay - Upgrades
- In-network: $0 copay
Out-of-network: $0 copay
Hearing Services
- Hearing exam
- In-network: $0 copay
Out-of-network: 50% coinsurance - Fitting/evaluation
- In-network: $0 copay
Out-of-network: 50% coinsurance - Prescription hearing aids
- In-network: $0 copay
Out-of-network: $0 copay - OTC hearing aids
- Not covered
Additional and Special Needs Services
- Adult day health services
- Not covered
- Home-based palliative care
- Not covered
- Personal emergency response system
- Coming soon
- Weight management programs
- Not covered
- Wigs for chemotherapy-related hair loss
- Coming soon
- Alternative therapies
- Not covered
- Massage therapy
- Not covered
- Home/bathroom safety devices
- Not covered
Certain preventive services are covered 100% by Allina Health Aetna Medicare Premier Extra as a Part B benefit.
Prescription Drug Coverage
Allina Health Aetna Medicare Premier Extra includes a Medicare Part D prescription drug plan (PDP). Plan type and coverage level are defined by CMS and may vary between basic and enhanced benefit designs.
This plan includes an enhanced benefit Medicare Part D plan (PDP), providing coverage beyond the standard CMS-defined minimum.
Prescription Drug Plan Premium
The Part D prescription drug plan premium is included in the overall Medicare Advantage plan cost. Additional adjustments may apply through the Low-Income Subsidy (LIS) program, also known as Extra Help, administered by Social Security. LIS benefits are separate from Medicare Special Needs Plan coverage.
| Part D Premium Component | Amount |
|---|---|
| Basic Part D Premium: | $67.20 |
| Supplemental Part D Premium: | $$0.00 |
| Total Part D Premium: | $67.20 |
| Low-Income Premium Subsidy: | $24.60 |
| Low-Income Premium Subsidy Paid by CMS: | $24.60 |
| Low-Income Subsidy Premium: | $42.60 |
For more details, visit the Social Security Extra Help program .
Prescription Drug Plan Deductible
This plan has a $300.00 annual Part D deductible. You'll pay this deductible at the pharmacy before Allina Health Aetna Medicare starts contributing towards your prescription costs.
Prescription Drug Plan Out-of-Pocket Costs
Beyond premiums and deductibles, Allina Health Aetna Medicare Premier Extra may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.
| Drug Tier | Retail | Mail Order |
|---|---|---|
| Preferred Generic | $0.00 copay | Coming soon |
| Generic | $5.00 copay | Coming soon |
| Preferred Brand | 18% coinsurance | Coming soon |
| Non-Preferred Drug | 30% coinsurance | Coming soon |
| Specialty Tier | 30% coinsurance | Coming soon |
| *Deductible does not apply. | ||
CMS 5-Star Performance Ratings (Contract ID: H3219)
CMS evaluates Medicare Advantage (Part C) and Part D plans annually using a 5-star rating system. Ratings reflect performance in preventive care, chronic condition management, and member experience.
| CMS Measure | Star Rating |
|---|---|
| 2027 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | |
| Managing Chronic (Long Term) Conditions | |
| Member Experience with Health Plan | |
| Complaints and Changes in Plans Performance | |
| Health Plan Customer Service | |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | |
| Member Experience with the Drug Plan | |
| Drug Safety and Accuracy of Drug Pricing |
Contact Information for Allina Health Aetna Medicare
- Website
- Allina Health Aetna Medicare Plan Page
- Providers
- Allina Health Aetna Medicare Providers Page
- Formulary
- Allina Health Aetna Medicare Formulary Page
- Pharmacy
- Allina Health Aetna Medicare Pharmacy Page
- New Member Health Plan Help
- (844)622-5862
- New Member Health Plan TTY
- 711
- New Member Part D Help
- (844)622-5862
- New Member Part D TTY Users
- 711
Enrollment status and eligibility information are available through the Social Security Administration. Additional information about Medicare Advantage is available at Medicare.gov.
Medicare Plan Data Sources and Methodology
| Data Source | Publisher | Last Accessed |
|---|---|---|
| Landscape Source Files | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Medicare Part C & D Performance | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Plan Benefits Package | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Monthly Enrollment by Contract/Plan/State/County | Centers for Medicare & Medicaid Services | October 5, 2026 |
Data sources and methodology documentation.
| Publisher | Reference | Last Accessed |
|---|---|---|
| Allina Health Aetna Medicare (official source) | http://www.AllinaHealthAetnaMedicare. | October 4, 2026 |
| CMS.gov | Medicare Advantage Plan Fact Sheet | 25 May, 2025 |
| AARP.org | The Big Choice: Original Medicare vs. Medicare Advantage | 25 May, 2025 |
| Medicare.gov | Your coverage options | 25 May, 2025 |
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