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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 Dallas and Surrounding Counties. This plan received an overall rating of 4 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 $50.00. 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 $10100.00 (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 $10100.00 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 drug deductible of $615. For Tier 1 preferred generics and Tier 2 generics, members enjoy no copay when using preferred pharmacies or preferred mail order services. If standard pharmacies or standard mail order options are used, Tier 1 drugs carry a copay starting at $2, while Tier 2 drugs start at a $12 copay. For higher-tier medications, the plan transitions from flat copays to coinsurance percentages. Tier 3 preferred brand drugs require a 24% coinsurance across all pharmacy and mail order options. Tier 4 non-preferred drugs and Tier 5 specialty drugs both require a 25% coinsurance payment.
Additional Benefits
The Aetna Medicare Enhanced (PPO) plan offers robust coverage for core medical services, featuring no copay or coinsurance for primary care visits and annual preventive screenings. Specialist visits range from no copay to a $35 copay, while emergency room care carries a $130 copay that is waived if you are admitted. For hospital stays, inpatient acute care requires a $395 daily copay for the first six days, and outpatient hospital visits range from no copay to a $350 copay. Beneficiaries also receive valuable supplemental coverage, including no copays or coinsurance for routine dental, vision, and hearing exams. The plan provides a $1,500 annual dental limit, a $275 yearly vision allowance, and up to $1,000 per ear for prescription hearing aids. Additionally, there is no copay for home health services and durable medical equipment, though some medical equipment and dialysis services require a 20% coinsurance.
Inpatient Hospital See details
Aetna Medicare Enhanced (PPO) partially covers inpatient hospital services with no coinsurance, requiring prior authorization. Acute care requires a $395 daily copay for days 1 to 6 and no copay for additional days, while psychiatric care requires a $300 daily copay for days 1 to 6 and no copay for days 7 to 90. 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, although copays and prior authorizations may apply. There is no copay for ambulatory surgical center and blood services, while outpatient hospital visits require a $0 to $350 copay, observation services require a $395 copay per stay, and outpatient substance abuse sessions carry a $35 copay.
Partial Hospitalization See details
Aetna Medicare Enhanced (PPO) covers partial hospitalization services with a copay of $85.00 or $145.00 and no coinsurance. Prior authorization is required to access this benefit.
Ambulance and Transportation Services See details
Aetna Medicare Enhanced (PPO) covers ground ambulance services with a $300 copay and no coinsurance, and air ambulance services with a 20% coinsurance and no copay, with prior authorization required for both. Routine transportation services to health-related locations are not covered under this plan.
Emergency Services See details
Aetna Medicare Enhanced (PPO) covers emergency services 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 with no coinsurance, and worldwide emergency services are covered up to $250,000 with no coinsurance and copays between $130 and $300.
Primary Care See details
Primary Care benefits under the Aetna Medicare Enhanced (PPO) plan feature no copay and no coinsurance for primary care visits, while specialist services range from a $0 to $35 copay with no coinsurance. Physical, occupational, speech, mental health, and psychiatric therapies require a $35 copay and no coinsurance, whereas chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive services are partially covered by the Aetna Medicare Enhanced (PPO) plan, offering no copay and no coinsurance for annual physicals, screenings, fitness benefits, and health education, though kidney disease education requires a 20% coinsurance with no copay. Several supplemental services are not covered under this benefit, including in-home safety assessments, personal emergency response systems, weight management, alternative therapies, and nutritional benefits.
Hearing Services See details
Aetna Medicare Enhanced (PPO) provides partially covered hearing services, including Medicare-covered exams for a $35 copay and no coinsurance, and routine exams and fitting evaluations with no copay and no coinsurance. Prescription hearing aids are covered with no copay or coinsurance up to a $1,000 annual limit per ear, but OTC hearing aids and inner ear, outer ear, and over-the-ear prescription hearing aids are not covered.
Vision Services See details
Vision services are covered by Aetna Medicare Enhanced (PPO) with no copays, coinsurance, or deductibles for exams and eyewear. Beneficiaries receive one routine eye exam per year up to a $50 maximum, alongside a combined $275 annual allowance for contacts, eyeglasses, and upgrades.
Dental Services See details
Aetna Medicare Enhanced (PPO) offers partially covered dental services up to a $1,500 annual limit, featuring no copay and no coinsurance for routine exams, cleanings, and x-rays. Medicare-covered dental requires a $35 copay and no coinsurance, while covered comprehensive services have no copay and 20% to 50% coinsurance. Fluoride, implants, orthodontics, maxillofacial prosthetics, other diagnostic, and other preventive dental services are not covered.
Home Infusion bundled Services See details
Aetna Medicare Enhanced (PPO) covers home infusion bundled services with no copay, though prior authorization and step therapy are required. Medicare Part B insulin drugs are covered with a $35 copay and no coinsurance, while Part B chemotherapy, radiation, and other drugs require a 0% to 20% coinsurance.
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
Medical Equipment is covered by Aetna Medicare Enhanced (PPO) with no copay for durable medical equipment (DME), prosthetics, medical supplies, and diabetic therapeutic shoes or inserts. Coinsurance for these covered items ranges from no coinsurance up to 20%, and prior authorization is required. Diabetic supplies are also covered but are limited to specified manufacturers.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under the Aetna Medicare Enhanced (PPO) plan, with prior authorization required for all services. Diagnostic tests range from a $0 to $50 copay with no coinsurance, while lab services, diagnostic radiology, and outpatient X-rays have no copay. Outpatient X-rays require coinsurance, and therapeutic radiological services carry a copay and a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered by the Aetna Medicare Enhanced (PPO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by Aetna Medicare Enhanced (PPO) with no coinsurance, but only some services are covered in practice. Specifically, cardiac rehabilitation (with a $20 copay), intensive cardiac rehabilitation (with a $20 copay), pulmonary rehabilitation (with a $15 copay), and SET for PAD services (with a $25 copay) are not covered.
Skilled Nursing Facility (SNF) See details
Skilled nursing facility (SNF) services are covered by Aetna Medicare Enhanced (PPO) with no coinsurance, requiring a $10 daily copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, a prior three-day hospital stay is not needed for admission, and additional days beyond the standard 100 days are not covered.
Other Services See details
Aetna Medicare Enhanced (PPO) offers partial coverage for other services, including over-the-counter items up to $50 every three months, annual wellness exams, screening mammographies, and additional gFOBT and FIT screenings with no copay and no coinsurance. Acupuncture and meal benefits are not covered under this plan.
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