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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 Upstate and Midlands South Carolina. 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. During the initial coverage phase, you will pay a copay or coinsurance depending on the drug tier and the pharmacy you use. For example, you will pay a $5 copay for preferred generic drugs at a preferred pharmacy, while standard generic drugs have a 25% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs.
Additional Benefits
The Aetna Medicare Prime (HMO-POS) plan offers a range of benefits with varying cost-sharing. Inpatient hospital stays have copays, while outpatient services have copays that vary by service type. Emergency, primary care, and preventive services often have no copay, and there are copays for specialist visits, hearing exams, and dental services. The plan provides coverage for vision, hearing, and dental services, with specific copays and annual maximums. Additional benefits include home health services with no copay, and coverage for medical equipment, diagnostic services, and skilled nursing facilities. There are also benefits for ambulance, partial hospitalization, and outpatient substance abuse services.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, but 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. For Inpatient Hospital-Acute, you pay a $295 copay for days 1-6, and no copay for days 7-90. For Inpatient Hospital Psychiatric, you pay a $318 copay for days 1-8, and no copay for days 9-90.
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 $295, observation services have a $295 copay, individual and group sessions for outpatient substance abuse have a $12 copay, and outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the Aetna Medicare Prime (HMO-POS) plan, but requires prior authorization. You will pay a $130 copay for this service.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by Aetna Medicare Prime (HMO-POS). 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 $12 copay, physician specialist services with a $12 copay, and mental health specialty services with a $12 copay for individual and group sessions. The plan also covers other health care professionals with a copay between $0 and $12, psychiatric services with a $12 copay for individual and group sessions, and physical therapy and speech-language pathology services with a $12 copay. Additional telehealth benefits are covered with a 20% coinsurance and a copay between $0 and $45, and opioid treatment program services are covered with a $12 copay. Podiatry services are not covered.
Preventive Services See details
The Aetna Medicare Prime (HMO-POS) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services, Health Education, Additional Sessions of Smoking and Tobacco Cessation Counseling, and Fitness Benefit have a $0 copay, and Wigs for Hair Loss Related to Chemotherapy has a $0 copay and a maximum benefit of $400 per year. Kidney Disease Education Services have a 20% coinsurance, while Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit have no copay.
Hearing Services See details
Hearing Services include coverage for hearing exams with a $12 copay, Routine Hearing Exams with no copay for up to one visit per year, and Fitting/Evaluation for Hearing Aid with no copay for up to one visit per year. Prescription Hearing Aids (all types) are covered with no copay for up to two visits per year, with a maximum plan benefit of $1250 per year. Prescription Hearing Aids - Inner Ear, Prescription Hearing Aids - Outer Ear, Prescription Hearing Aids - Over the Ear, 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-$12, routine eye exams with no copay, and other eye exam services with no copay. Eyewear benefits are covered with no copay, and include contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades. This plan offers a combined maximum of $235 per year for eyewear.
Dental Services See details
Dental services include coverage for Medicare dental services with a $12 copay, and other dental services are covered with a $2,500 annual maximum. 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, while maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, coinsurance ranges from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered by the Aetna Medicare Prime (HMO-POS) plan, with a coinsurance between 20% and 20%. Prior authorization is required.
Medical Equipment See details
Medical Equipment is covered under the Aetna Medicare Prime (HMO-POS) plan. Durable Medical Equipment (DME) has a coinsurance between 0% and 20%, and Prosthetic Devices have a 20% coinsurance; however, Durable Medical Equipment for use outside the home is not covered. Diabetic Supplies have a coinsurance between 0% and 20%, and Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including all diagnostic services, diagnostic procedures/tests, lab services, all radiological services, diagnostic radiological services, therapeutic radiological services, and outpatient X-ray services are covered. Diagnostic Procedures/Tests have a copay between $0 and $120, while Lab Services have no copay. Diagnostic Radiological Services have a copay of at most $200, and Therapeutic Radiological Services have a coinsurance of at least 20%. Outpatient X-Ray Services have a copay of $14.
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 the benefit in general, specific services such as Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation 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, but require prior authorization. For days 1-20, the copay is $20 per day, and for days 21-100, the copay is $214 per day; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services include Over-the-Counter (OTC) Items and Meal Benefits with no copay, as well as "Other 1" and "Other 2" services, also with no copay. Acupuncture, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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