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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 2025, 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 Triad and Piedmont Area NC. This plan received an overall rating of 4 out of 5 stars in 2025.
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 no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $4150.00 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 has a $0 deductible for prescription drugs. In the initial coverage phase, you'll pay a copay or coinsurance depending on the drug tier and pharmacy you use. For example, preferred generic drugs have a $5 copay at preferred pharmacies. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for covered Part D drugs. This plan's premium may be reduced if you qualify for the low-income subsidy (LIS).
Additional Benefits
The Aetna Medicare Prime (HMO-POS) plan offers a wide range of benefits with varying costs. The plan covers inpatient hospital stays with copays, as well as outpatient services, emergency services, and primary care, often with copays. Additionally, the plan includes preventive services, hearing, vision, and dental coverage with no or low copays for many services. This plan also offers coverage for ambulance services, home health, and skilled nursing facilities with copays or coinsurance. Diagnostic and radiological services, medical equipment, and home infusion are covered with copays or coinsurance. However, the plan does not cover certain services like cardiac rehabilitation, acupuncture, and some other specialized services.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, you pay a $415 copay for days 1-8, and no copay for days 9-90; for Inpatient Hospital Psychiatric, you pay a $318 copay for days 1-8, and no copay for days 9-90. Non-Medicare-covered stay and upgrades for Inpatient Hospital-Acute, and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including outpatient hospital services, observation services, and outpatient substance abuse services, are covered. Outpatient hospital services have a copay between $0 and $415, observation services have a $415 copay, and outpatient substance abuse services have a $40 copay for both individual and group sessions. Ambulatory Surgical Center services and outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Aetna Medicare Prime (HMO-POS) plan, but requires prior authorization. You will have a $130 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Aetna Medicare Prime (HMO-POS) plan, with prior authorization required for all ambulance services. Ground ambulance services have a $275 copay, while air ambulance services have a 20% coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Aetna Medicare Prime (HMO-POS) plan. Emergency Services have a $140 copay, Urgently Needed Services have a $45 copay, and Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $140 copay, while Worldwide Emergency Transportation has a $275 copay.
Primary Care See details
The Aetna Medicare Prime (HMO-POS) plan covers primary care physician services with no copay, chiropractic services with a $20 copay, occupational therapy services with a $30 copay, and physician specialist services with a $15 copay. Mental health specialty services, including individual and group sessions, have a $40 copay. Other health care professional services have a copay between $0 and $15, and physical therapy and speech-language pathology services have a $30 copay. Additional telehealth benefits are covered with a 20% coinsurance and a copay between $0 and $45. Opioid treatment program services have a $40 copay. Podiatry services are not covered.
Preventive Services See details
Preventive services include an annual physical exam with no copay, and other preventive services including health education, wigs for hair loss related to chemotherapy, additional sessions of smoking and tobacco cessation counseling, fitness benefits, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a welcome visit with no copay. Kidney disease education services have a 20% coinsurance. In-home safety assessment, personal emergency response system (PERS), medical nutrition therapy (MNT), post-discharge in-home medication reconciliation, re-admission prevention, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefit, home-based palliative care, in-home support services, and support for caregivers of enrollees are not covered.
Hearing Services See details
The Aetna Medicare Prime (HMO-POS) plan covers hearing exams with a $15 copay, and also covers routine hearing exams and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered, but inner ear, outer ear, and over the ear hearing aids are not covered, and OTC hearing aids are not covered.
Vision Services See details
The Aetna Medicare Prime (HMO-POS) plan covers vision services, including eye exams with a copay of $0-$15 and eyewear with no copay. Routine eye exams are covered with no copay for one visit per year, while other eye exam services and eyewear benefits like contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades have no copay.
Dental Services See details
Dental services are covered with a $15 copay for Medicare Dental Services, with prior authorization required. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery have no copay. Maxillofacial prosthetics, implant services, and orthodontics are not covered. There is a $2,500 annual maximum for other dental services.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs are also covered with a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Aetna Medicare Prime (HMO-POS) plan, but require prior authorization. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical equipment, including durable medical equipment and prosthetic devices, is covered by the Aetna Medicare Prime (HMO-POS) plan, with coinsurance ranging from 0% to 20%. Diabetic supplies are covered with coinsurance between 0% and 20%, and Diabetic Therapeutic Shoes/Inserts are covered with no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Aetna Medicare Prime (HMO-POS) plan, with Diagnostic Procedures/Tests having a copay between $0 and $100, and Lab Services having no copay. Diagnostic Radiological Services have a maximum copay of $300, while Therapeutic Radiological Services have a coinsurance of at least 20%, and Outpatient X-Ray Services have a $14 copay.
Home Health Services See details
Home Health Services are covered by the Aetna Medicare Prime (HMO-POS) plan with no copay and no coinsurance. Additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Aetna Medicare Prime (HMO-POS) plan. While the plan covers Cardiac Rehabilitation Services, the specific services of Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Aetna Medicare Prime (HMO-POS) plan. For days 1-20, the copay is $20, and for days 21-100, the copay is $214; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The Aetna Medicare Prime (HMO-POS) plan covers Over-the-Counter (OTC) Items and Meal Benefits with no copay, but does not cover Acupuncture. Other services, including Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), and other services, are not covered.
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