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Aetna Medicare Elite (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare Elite (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Aetna Medicare Elite (PPO) in 2026, please refer to our full plan details page.
This summary reflects 2026 plan information. Where this plan continues in 2027, the full plan details page links to its 2027 benefits and costs.
Aetna Medicare Elite (PPO) is a PPO plan offered by Coventry Health and Life Insurance Company available for the 2026 plan year to people living in St. Joe and Surrounding Area. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that Aetna Medicare Elite (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 Elite (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 Elite (PPO), 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 has a $1500.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $615.00 drug deductible that applies only to drugs in certain tiers. You pay this amount toward covered prescriptions in those tiers before the plan's cost sharing begins; drugs in the other tiers are not subject to the deductible. See the full plan details page for the tier table.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $6750.00 for in-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $6750.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
This plan has a Maximum Out-Of-Pocket cost of $10100.00 (in-network and out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $10100.00 for covered services, the plan will pay 100% of 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 Elite (PPO) plan features an annual drug deductible of $615. For Tier 1 preferred generic and Tier 2 generic medications, there is no copay when filled through a preferred pharmacy or preferred mail-order service. If you use a standard pharmacy or standard mail-order, Tier 1 copays start at $2.00 and Tier 2 copays start at $12.00 for a one-month supply. For higher-tier medications, costs are based on coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 24% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs both carry a 25% coinsurance. These coinsurance percentages remain the same across all preferred and standard pharmacy and mail-order options.
Additional Benefits
The Aetna Medicare Elite (PPO) plan offers strong coverage for routine care, featuring no copays or coinsurance for primary care visits, preventive screenings, and routine dental cleanings. Members also benefit from no copays on routine vision and hearing exams, which include allowances for prescription eyewear and hearing aids. For emergency and urgent care, the plan provides worldwide protection with fixed copays, including an emergency room copay that is waived upon hospital admission. For specialized and inpatient care, specialist office visits carry a low copay of up to sixty-five dollars, while home health services are fully covered with no copay. Inpatient hospital stays require a daily copay for the first six days, after which there is no copay for the remainder of your stay. Other services, such as outpatient surgeries and laboratory tests, feature no copays, while durable medical equipment and dialysis require up to a twenty percent coinsurance.
Inpatient Hospital See details
Inpatient hospital care is partially covered by Aetna Medicare Elite (PPO) with no coinsurance, though upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered. Acute stays require a $450 daily copay for days 1 through 6 and no copay for subsequent days, while psychiatric stays require a $390 daily copay for days 1 through 6 and no copay for days 7 through 90.
Outpatient Services See details
Aetna Medicare Elite (PPO) outpatient services are covered with no coinsurance, featuring no copays for ambulatory surgical center and outpatient blood services. Outpatient hospital services require a copay of $0 to $400, while observation services carry a $450 copay per stay and outpatient substance abuse sessions have a $65 copay.
Partial Hospitalization See details
Aetna Medicare Elite (PPO) covers partial hospitalization services with a copay of either $55.00 or $145.00 and no coinsurance. Prior authorization is required for these covered services.
Ambulance and Transportation Services See details
Aetna Medicare Elite (PPO) covers ground ambulance services with a $350 copay and air ambulance services with a 20% coinsurance, with prior authorization required for both. Transportation services are not covered under this plan.
Emergency Services See details
Emergency services under Aetna Medicare Elite (PPO) are covered with a $130 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $50 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered up to a $250,000 maximum with no coinsurance and copays ranging from $130 to $350.
Primary Care See details
Primary care benefits under the Aetna Medicare Elite (PPO) feature primary care physician visits with no copay and no coinsurance, and specialist visits with a $0 to $65 copay and no coinsurance. Physical, occupational, and mental health therapies require a $50 to $65 copay and no coinsurance, while chiropractic services are not covered. Telehealth services are also offered with a $0 to $65 copay and 20% coinsurance.
Preventive Services See details
Aetna Medicare Elite (PPO) preventive services are partially covered with no copay and no coinsurance for annual exams and screenings, while kidney disease education has a 20% coinsurance and no copay. Supplemental benefits like fitness and health education have no copay and no coinsurance, but chemotherapy wigs are limited to a $400 annual maximum. Sub-services not covered include in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, palliative care, in-home support, caregiver support, enhanced disease management, telemonitoring, home safety devices, and counseling.
Hearing Services See details
Aetna Medicare Elite (PPO) provides partially covered hearing services, featuring a $65 copay and no coinsurance for Medicare-covered exams, and no copay or coinsurance for annual routine exams and fitting evaluations. While prescription hearing aids are covered with no copay or coinsurance up to $500 per ear annually, inner ear, outer ear, over-the-ear, and OTC hearing aids are not covered.
Vision Services See details
Aetna Medicare Elite (PPO) offers vision services with no copay, no coinsurance, and no deductible for both eye exams and eyewear. This includes coverage for one routine eye exam per year up to a $50 maximum, alongside a combined $100 annual allowance for contacts, eyeglasses, frames, and upgrades.
Dental Services See details
Dental services are partially covered by the Aetna Medicare Elite (PPO) plan, with Medicare-covered dental requiring a $65 copay and no coinsurance. Covered preventive care like oral exams, cleanings, and X-rays has no copay and no coinsurance, while fluoride, restorative, endodontic, periodontic, prosthodontic, implant, and orthodontic services are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Aetna Medicare Elite (PPO) with no copay, though prior authorization is required. Covered Medicare Part B insulin drugs require a $35 copay and no coinsurance, while Part B chemotherapy, radiation, and other drugs carry a 0% to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered by the Aetna Medicare Elite (PPO) with no copay and a 20% coinsurance, although prior authorization is required.
Medical Equipment See details
Aetna Medicare Elite (PPO) covers medical equipment with no copays, though prior authorization is required for all categories. Durable medical equipment, diabetic supplies, and medical supplies range from no coinsurance to 20% coinsurance, while prosthetic devices and diabetic therapeutic shoes or inserts require a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Aetna Medicare Elite (PPO) and require prior authorization. Lab services and outpatient x-rays have no copay, diagnostic tests range from a $0 to $55 copay with no coinsurance, and therapeutic radiological services require a minimum 20% coinsurance.
Home Health Services See details
Aetna Medicare Elite (PPO) covers home health services 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 Elite (PPO) plan, which features no coinsurance and a $5 copay for all rehabilitation sub-services.
Skilled Nursing Facility (SNF) See details
Aetna Medicare Elite (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but allowing admission without a prior three-day inpatient hospital stay. You will pay a $10 copayment per day for days 1 through 20 and a $218 copayment per day for days 21 through 100, with no coverage provided for additional days.
Other Services See details
Other Services under the Aetna Medicare Elite (PPO) are partially covered, featuring acupuncture for up to 12 treatments per year with a $20 copay and no coinsurance, alongside annual wellness exams and additional colorectal screenings with no copay and no coinsurance. Over-the-counter (OTC) items, meal benefits, and dual-eligible SNPs are not covered.
Plan Providers
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, Health Care Service Corporation, HealthSpringSM, HealthSun, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
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1-877-649-2073 / TTY 711. Call-center hours (ET): Mon-Fri 8am-10pm; Sat 9am-8pm; Sun closed.
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