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Aetna Medicare Enhanced (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare Enhanced (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Aetna Medicare Enhanced (PPO) in 2026, please refer to our full plan details page.
Aetna Medicare Enhanced (PPO) is a PPO plan offered by CVS Health Corporation available for enrollment in 2025 to people living in Missouri/Illinois. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that Aetna Medicare Enhanced (PPO) 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 Enhanced (PPO).
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 Enhanced (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $60.00. 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 combined Maximum Out-Of-Pocket cost of $13900.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $13900.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
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 Enhanced (PPO) plan features an annual prescription drug deductible of $615. For Tier 1 preferred generic and Tier 2 generic drugs, you will pay no copay when using a preferred pharmacy or preferred mail-order service for up to a three-month supply. If you choose a standard pharmacy or standard mail order, Tier 1 copays range from $2 to $6, while Tier 2 copays range from $12 to $36 depending on the supply duration. For higher-tier medications, costs transition to coinsurance instead of flat copays. Tier 3 preferred brand-name drugs require a 24% coinsurance across all pharmacy and mail-order options. Non-preferred drugs in Tier 4 and specialty drugs in Tier 5 both carry a 25% coinsurance, with Tier 5 coverage limited to a one-month supply.
Additional Benefits
The Aetna Medicare Enhanced (PPO) plan offers comprehensive coverage for essential medical needs, featuring no copay and no coinsurance for primary care visits and routine preventive care. Specialist visits and outpatient therapies are available with low, predictable copays and no coinsurance, while emergency room visits require a $115 copay that is waived upon admission. For inpatient hospital stays, members pay a daily copay for the first six days of their stay, after which there is no copay. This plan also includes valuable supplemental benefits, offering routine dental, vision, and hearing exams with no copay alongside annual allowances for eyewear and prescription hearing aids. Members can also take advantage of home health services with no copay, a quarterly over-the-counter item allowance, and covered diagnostic services. With clear copay structures and no coinsurance on many key services, this plan is designed to help keep your healthcare costs predictable and manageable.
Inpatient Hospital See details
Aetna Medicare Enhanced (PPO) partially covers inpatient hospital services with no coinsurance, featuring a $350 daily copay for days 1 to 6 of acute stays (no copay for days 7 and beyond) and a $345 daily copay for days 1 to 6 of psychiatric stays (no copay for days 7 to 90). Prior authorization is required, and upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Aetna Medicare Enhanced (PPO) covers outpatient services with no coinsurance, including outpatient hospital services with a $0 to $300 copay and observation services with a $350 copay per stay. Ambulatory surgical center and blood services are covered with no copay and no coinsurance, while individual and group outpatient substance abuse sessions require a $45 copay and no coinsurance.
Partial Hospitalization See details
Aetna Medicare Enhanced (PPO) covers partial hospitalization services with a copay of either $60.00 or $110.00 and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by Aetna Medicare Enhanced (PPO), with ground ambulance services requiring a $300 copay and no coinsurance, and air ambulance services requiring no copay and a 20% coinsurance. Prior authorization is required for all ambulance services, and although transportation is listed as covered, some services are covered but transportation to plan-approved or any health-related locations is not covered.
Emergency Services See details
Aetna Medicare Enhanced (PPO) covers emergency services with a $115 copay (waived if admitted within 24 hours) and urgent care with a $40 copay, with no coinsurance for either service. Worldwide emergency services are also covered with no coinsurance and copays up to $300, up to a maximum plan benefit of $250,000.
Primary Care See details
Aetna Medicare Enhanced (PPO) offers primary care services with no copay and no coinsurance, specialist visits with a $0 to $45 copay and no coinsurance, and telehealth services with a $0 to $45 copay and 20% coinsurance. Physical, occupational, and speech therapies require a $35 copay, while mental health, psychiatric, opioid treatment, and routine podiatry require a $45 copay—all with no coinsurance—though chiropractic services are not covered.
Preventive Services See details
Aetna Medicare Enhanced (PPO) covers preventive services with no copay and no coinsurance for annual physicals, screenings, and fitness benefits, though kidney disease education requires a 20% coinsurance and no copay. Additional preventive benefits are partially covered, excluding services such as in-home safety assessments, weight management, medical nutrition therapy, therapeutic massage, and personal emergency response systems.
Hearing Services See details
Aetna Medicare Enhanced (PPO) covers Medicare-covered hearing exams for a $45 copay and no coinsurance, while annual routine exams and fittings have no copay, no coinsurance, and no deductible. Prescription hearing aids are partially covered with no copay or coinsurance up to a $1,250 maximum per ear annually, but OTC, inner ear, outer ear, and over-the-ear hearing aids are not covered.
Vision Services See details
Aetna Medicare Enhanced (PPO) covers vision services with no copays, no coinsurance, and no deductibles for both eye exams and eyewear. The plan includes a $50 annual maximum for eye exams, which covers one routine exam per year, and a $200 yearly allowance for contacts, eyeglasses, lenses, frames, and upgrades.
Dental Services See details
Dental services covered by the Aetna Medicare Enhanced (PPO) include Medicare-covered dental care for a $45 copay and no coinsurance, as well as routine exams and cleanings with no copay and no coinsurance. Comprehensive treatments are covered with no copay and 20% to 50% coinsurance up to a $1,500 annual maximum, though fluoride, implants, orthodontics, and maxillofacial prosthetics are not covered.
Home Infusion bundled Services See details
Aetna Medicare Enhanced (PPO) covers Home Infusion bundled Services with no copay and no coinsurance, although prior authorization and step therapy may be required. Under this plan, Medicare Part B insulin drugs have a $35 copay and no coinsurance, while chemotherapy and other Part B drugs have a 0% to 20% coinsurance with no copay.
Dialysis Services See details
Dialysis services are covered under the Aetna Medicare Enhanced (PPO) plan with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
Aetna Medicare Enhanced (PPO) covers durable medical equipment (DME) and medical supplies with no copay and 0% to 20% coinsurance, while prosthetic devices require no copay and 20% coinsurance. Diabetic supplies from specified manufacturers carry 0% to 20% coinsurance, and diabetic therapeutic shoes or inserts require a $10 copay and no coinsurance, with prior authorization required for these benefits.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Aetna Medicare Enhanced (PPO), with prior authorization required for these services. Diagnostic services feature no coinsurance, with no copay for lab work and a $0 to $45 copay for diagnostic procedures, while radiological services require no copay for X-rays and diagnostic radiology, and a minimum 20% coinsurance for therapeutic radiology.
Home Health Services See details
Home Health Services are covered under the Aetna Medicare Enhanced (PPO) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are offered by Aetna Medicare Enhanced (PPO) with no coinsurance, meaning some services are covered. However, cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered and require a $5 copay.
Skilled Nursing Facility (SNF) See details
Aetna Medicare Enhanced (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day hospital stay. Patients pay no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, with no coverage for additional days beyond the standard Medicare limit.
Other Services See details
Aetna Medicare Enhanced (PPO) offers partial coverage for other services with no copay and no coinsurance for covered benefits, which include meal benefits for chronic illness, annual wellness exams and screening mammography, additional gFOBT and FIT, and up to $30 every three months for over-the-counter items. Acupuncture is not covered under this plan.
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