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Aetna Medicare Prime (HMO-POS)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare Prime (HMO-POS). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Aetna Medicare Prime (HMO-POS) in 2026, please refer to our full plan details page.
Aetna Medicare Prime (HMO-POS) is a HMO-POS plan offered by CVS Health Corporation available for enrollment in 2025 to people living in Orange County. This plan received an overall rating of 3 out of 5 stars in 2026.
It's important to know that Aetna Medicare Prime (HMO-POS) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Aetna Medicare Prime (HMO-POS).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Aetna Medicare Prime (HMO-POS), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $615.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $599.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Aetna Medicare Prime (HMO-POS) plan features an enhanced alternative drug benefit with an annual prescription drug deductible of $615.00. After meeting this deductible, you will enjoy no copay for Tier 1 preferred generic drugs at preferred pharmacies or through preferred mail order, while standard pharmacies and standard mail options require a $12.00 copay. For Tier 2 standard generic drugs, there is a 24% coinsurance, while Tier 3 preferred brand and Tier 4 non-preferred drugs require a 25% coinsurance. Once your yearly out-of-pocket drug costs reach $2,100.00, you enter the catastrophic coverage phase and will pay nothing for covered Medicare Part D prescription drugs. Additionally, beneficiaries who qualify for the low-income subsidy can see their Part D costs reduced to zero. This plan provides a structured approach to managing your prescription expenses with clear copay and coinsurance tiers.
Additional Benefits
The Aetna Medicare Prime (HMO-POS) plan offers comprehensive coverage with no copay and no coinsurance for many essential services, including Medicare-covered inpatient hospital stays, outpatient services, and primary care or specialist visits. Emergency care is available with a $150 copay, which is waived if you are admitted, while urgent care services require no copay. For specialized care, skilled nursing facility stays feature no copay for the first 20 days, and diagnostic services like lab tests and X-rays are also covered with no copay. This plan also provides valuable supplemental benefits, including routine vision and hearing exams with no copay, alongside annual allowances of up to $250 for eyewear and $500 per ear for prescription hearing aids. Preventive dental care is covered with no copay, while comprehensive dental services require a 20% to 50% coinsurance. Additionally, members can access fitness benefits, acupuncture, and over-the-counter items with no copay and no coinsurance.
Inpatient Hospital See details
Aetna Medicare Prime (HMO-POS) partially covers inpatient hospital services, offering Medicare-covered acute and psychiatric stays with no copay and no coinsurance, though prior authorization is required. However, non-Medicare-covered stays, hospital upgrades, and additional days for psychiatric care are not covered.
Outpatient Services See details
Aetna Medicare Prime (HMO-POS) covers outpatient services with no copay and no coinsurance for outpatient hospital, observation, ambulatory surgical center, and blood services. Outpatient substance abuse group and individual sessions are covered with a $10 copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization benefits are covered by Aetna Medicare Prime (HMO-POS) and require prior authorization. Covered services feature no coinsurance, with copays ranging from no copay to $180.
Ambulance and Transportation Services See details
Aetna Medicare Prime (HMO-POS) partially covers ambulance and transportation services, though transportation to plan-approved or any health-related locations is not covered. Ground ambulance services require a $275 copay and no coinsurance, while air ambulance services require a 20% coinsurance and no copay.
Emergency Services See details
Aetna Medicare Prime (HMO-POS) covers emergency services with a $150 copay and no coinsurance, which is waived if admitted to the hospital within 24 hours, and urgently needed services with no copay and no coinsurance. Worldwide emergency, urgent, and transportation services are also covered up to a $250,000 maximum limit with copays ranging from $150 to $275 and no coinsurance.
Primary Care See details
Primary Care benefits are partially covered by Aetna Medicare Prime (HMO-POS), as podiatry services are not covered. Most covered services, including primary care and specialist visits, require no copay and no coinsurance, while mental health and psychiatric services have a $10 copay with no coinsurance, and telehealth benefits feature a 20% coinsurance and a $0 to $10 copay.
Preventive Services See details
Preventive services are partially covered by Aetna Medicare Prime (HMO-POS), featuring no copays or coinsurance for annual exams, fitness benefits, and health education, but requiring a 20% coinsurance and no copay for kidney disease education. Sub-services not covered include in-home safety assessments, PERS, medical nutrition therapy, medication reconciliation, readmission prevention, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, palliative care, in-home support, caregiver support, disease management, telemonitoring, home safety devices, and counseling.
Hearing Services See details
Aetna Medicare Prime (HMO-POS) covers routine hearing exams and fitting evaluations with no copay and no coinsurance. Prescription hearing aids are partially covered with no copay and no coinsurance up to a $500 annual limit per ear, but OTC hearing aids and inner, outer, or over-the-ear prescription aids are not covered.
Vision Services See details
Aetna Medicare Prime (HMO-POS) covers vision services with no deductibles, copayments, or coinsurance, including one routine eye exam per year and unlimited follow-up diabetic eye exams. Covered eyewear, such as contact lenses and eyeglasses, also features no copay or coinsurance up to a combined maximum benefit of $250 annually.
Dental Services See details
Aetna Medicare Prime (HMO-POS) partially covers dental services, offering preventive care and Medicare-covered dental services with no copay, and comprehensive services with a 20% to 50% coinsurance. Fluoride treatments, implants, orthodontics, and maxillofacial prosthetics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by Aetna Medicare Prime (HMO-POS) with prior authorization. Covered Part B insulin drugs require a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs feature no copay and up to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by Aetna Medicare Prime (HMO-POS) with a 20% coinsurance and no copay, though prior authorization is required.
Medical Equipment See details
Medical equipment benefits are covered by Aetna Medicare Prime (HMO-POS), with prior authorization required for most services. Durable medical equipment and diabetic supplies require no copay and 0% to 20% coinsurance, prosthetic devices require 20% coinsurance and no copay, and medical supplies and diabetic shoes feature no copay or coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Aetna Medicare Prime (HMO-POS) with no coinsurance, featuring no copay for lab services, diagnostic tests, outpatient X-rays, and diagnostic radiology. Therapeutic radiological services require a $60 copay, and prior authorization is required for radiological and diagnostic services.
Home Health Services See details
Aetna Medicare Prime (HMO-POS) covers Home Health Services with no copay and no coinsurance. Prior authorization is required to receive these covered services.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered in practice under the Aetna Medicare Prime (HMO-POS) plan. Although the plan indicates some services are covered, none of the sub-services—including cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation—are covered, meaning there are no plan-covered benefits, copayments, or coinsurance costs.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are partially covered by Aetna Medicare Prime (HMO-POS) with prior authorization required, as additional days beyond Medicare-covered stays are not covered. Patients pay no copay and no coinsurance for days 1 through 20, and a $50 copay with no coinsurance for days 21 through 100.
Other Services See details
Other Services are partially covered by Aetna Medicare Prime (HMO-POS), featuring acupuncture, over-the-counter items, and select wellness screenings with no copay and no coinsurance. Meal benefits and Dual Eligible SNPs with Highly Integrated Services are not covered.
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