Retirees and Dependents Eligible for Medicare
Plan Documents and Coverage
The Preferred Provider Option ("PPO") plan offers benefits beyond Original Medicare (Parts A & B). Members of the PPO plan must live in the plan service area.
- PPO General Information (PDF)
- 2024 PPO Benefit Overview (PDF)
- 2024 PPO Annual Notice of Change (PDF)
- 2023 PPO Benefit Overview (PDF)
- 2023 PPO Annual Notice of Change (PDF)
- 2022 PPO Benefit Overview (PDF)
- 2022 PPO Annual Notice of Change (PDF)
- 2021 PPO Benefit Overview (PDF)
- 2021 PPO Annual Notice of Change (PDF)
- 2020 PPO Benefit Overview (PDF)
- 2020 PPO Annual Notice of Change (PDF)
- 2020 Evidence of Coverage (PDF)
- 2020 Prescription Formulary (PDF)
This PPO plan has an Extended Service Area ("ESA"). This means that you may enroll in the plan even if you live outside the Aetna Medicare network service area. To confirm if you reside in a county that qualifies for this plan, contact Aetna Medicare Member Services at 1-888-267-2637.
- ESA General Information (PDF)
- 2024 ESA Benefit Overview (PDF)
- 2024 ESA Annual Notice of Change (PDF)
- 2023 ESA Benefit Overview (PDF)
- 2023 ESA Annual Notice of Change (PDF)
- 2022 ESA Benefit Overview (PDF)
- 2022 ESA Annual Notice of Change (PDF)
- 2021 ESA Benefit Overview (PDF)
- 2020 ESA Benefit Overview (PDF)
- 2020 ESA Annual Notice of Change (PDF)
- 2020 Evidence of Coverage (PDF)
- 2020 Prescription Formulary (PDF)
Effective January 1, 2024 through December 31, 2024
| Level of Coverage | Monthly Pension Deduction | Monthly State Contribution |
|---|---|---|
| Retiree | $0 | $156.40 |
| Spouse | $156.40 | $0 |
| Surviving Spouse | $156.40 | $0 |
Effective January 1, 2023 through December 31, 2023
| Level of Coverage | Monthly Pension Deduction | Monthly State Contribution |
|---|---|---|
| Retiree | $0 | $237.43 |
| Spouse | $237.43 | $0 |
| Surviving Spouse | $237.43 | $0 |
Note, rates do not reflect retirees who receive a pro-rated contribution. See governing statutes for more information. For questions please contact our office at 1-800-422-4503.
Premium Rates for active employees and retirees not eligible for Medicare