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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 San Diego 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 $300.00 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 $1500.00 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 offers an enhanced alternative drug benefit with a $300 annual prescription drug deductible. In the initial coverage phase, Tier 1 preferred generic drugs cost a $10 copay at preferred pharmacies and mail order, or a $12 copay at standard pharmacies. Other tiers require coinsurance, including 25% for standard generics, 26% for preferred brands, and 29% for non-preferred drugs. After your yearly out-of-pocket drug costs reach $2,100, you enter the catastrophic coverage phase and have no copay for covered Part D drugs. Additionally, members who qualify for the low-income subsidy will pay nothing for their Part D coverage. This structured plan helps beneficiaries clearly anticipate their prescription drug costs throughout the year.
Additional Benefits
The Aetna Medicare Prime (HMO-POS) plan offers robust medical coverage with no copay and no coinsurance for primary care, specialist visits, routine lab work, and home health care. For hospital stays, members pay a $200 daily copay for the first five days of inpatient care followed by no copay, while outpatient hospital services range from no copay to a $100 copay. Emergency room visits carry a $150 copay that is waived upon admission, while urgent care services are available with no copay. In addition to medical care, the plan features valuable supplemental benefits, including routine dental, vision, and hearing exams with no copay or coinsurance. Vision eyewear is covered up to a $250 annual limit, and prescription hearing aids are covered up to $1,250 per ear annually with no copay. Comprehensive dental services are also covered up to a $1,500 annual limit with a 20% to 50% coinsurance and no copay.
Inpatient Hospital See details
Aetna Medicare Prime (HMO-POS) partially covers inpatient hospital services with no coinsurance, requiring prior authorization and a $200 daily copay for days 1 through 5, followed by no copay for days 6 through 90 for both acute and psychiatric stays. Non-Medicare-covered stays, upgrades, and additional inpatient psychiatric days are not covered.
Outpatient Services See details
Outpatient services are covered by Aetna Medicare Prime (HMO-POS) with no coinsurance, including ambulatory surgical center, outpatient blood, and outpatient substance abuse services with no copay. Outpatient hospital services require a copay ranging from no copay to $100, while outpatient observation services carry a $200 copay per stay.
Partial Hospitalization See details
Partial hospitalization benefits are covered by Aetna Medicare Prime (HMO-POS) with copays ranging from no copay to $180, and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
Ambulance services are covered by Aetna Medicare Prime (HMO-POS) with a $245 copay and no coinsurance for ground transportation, and a 20% coinsurance with no copay for air transportation. Prior authorization is required for ambulance services, and additional transportation services to health-related locations are not covered.
Emergency Services See details
Aetna Medicare Prime (HMO-POS) covers emergency services with a $150 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services have no copay and no coinsurance, while worldwide emergency and urgent services are covered up to a $250,000 lifetime maximum with copays ranging from $150 to $245 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 under this plan. Covered services such as primary care, specialist, and therapy visits require no copay and no coinsurance, while additional telehealth services require a 20% coinsurance and no copay.
Preventive Services See details
Preventive services are partially covered by Aetna Medicare Prime (HMO-POS), featuring no copay and no coinsurance for annual physical exams, select screenings, and memory fitness, while kidney disease education requires a 20% coinsurance. Supplemental services such as in-home safety assessments, personal emergency response systems, medical nutrition therapy, and weight management programs are not covered.
Hearing Services See details
Hearing services are partially covered by Aetna Medicare Prime (HMO-POS), featuring no copay or coinsurance for annual routine hearing exams and fitting evaluations. While prescription hearing aids are covered up to $1,250 per ear annually with no copay or coinsurance, OTC hearing aids as well as inner-ear, outer-ear, and over-the-ear prescription models are not covered.
Vision Services See details
Aetna Medicare Prime (HMO-POS) covers vision services with no copay and no coinsurance, including one routine eye exam per year and follow-up diabetic eye exams. Eyewear, including contacts, eyeglasses, and upgrades, is also covered with no copay or coinsurance up to a $250 annual maximum.
Dental Services See details
Aetna Medicare Prime (HMO-POS) provides partial dental coverage, including Medicare-covered dental and preventive services like exams and cleanings with no copay or coinsurance. Comprehensive services are covered up to a $1,500 annual limit with a 20% to 50% coinsurance and no copay, though fluoride, implants, maxillofacial prosthetics, and orthodontics are not covered.
Home Infusion bundled Services See details
Aetna Medicare Prime (HMO-POS) covers home infusion bundled services with prior authorization, requiring a $35 copay and no coinsurance for Part B insulin. Other covered Part B chemotherapy, radiation, and miscellaneous drugs require no copay and carry a coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Dialysis services are covered by Aetna Medicare Prime (HMO-POS) with a 20% coinsurance and no copay. Prior authorization is required to receive this benefit.
Medical Equipment See details
Aetna Medicare Prime (HMO-POS) covers medical equipment with prior authorization and no copays across all services. Durable medical equipment and diabetic supplies require no coinsurance to 20% coinsurance, prosthetic devices carry a 20% coinsurance, and medical supplies and diabetic therapeutic shoes or inserts have no coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Aetna Medicare Prime (HMO-POS) with no coinsurance. There is no copay for lab services, diagnostic procedures, diagnostic radiology, and outpatient X-rays, while therapeutic radiological services require a $60 copay.
Home Health Services See details
Home Health Services are covered by Aetna Medicare Prime (HMO-POS) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Aetna Medicare Prime (HMO-POS) plan, as none of the sub-services—including intensive cardiac, pulmonary, and SET for PAD services—are covered in practice. Because these benefits are not covered, members do not have any copay or coinsurance responsibilities for them.
Skilled Nursing Facility (SNF) See details
Aetna Medicare Prime (HMO-POS) partially covers Skilled Nursing Facility (SNF) care, requiring prior authorization but no prior three-day inpatient hospital stay. There is no copay and no coinsurance for days 1 through 20, and a $100 daily copay with no coinsurance for days 21 through 100, though additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other services are partially covered by Aetna Medicare Prime (HMO-POS) with no copay and no coinsurance for acupuncture, over-the-counter items, and select wellness screenings. Meal benefits and dual eligible SNPs with highly integrated services are not covered under this plan.
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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
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