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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 2026, 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 Counties: BR, HT, MR, MN, MO, PS, SM, SX, UN, WR. This plan received an overall rating of 4 out of 5 stars in 2026.
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 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 Maximum Out-Of-Pocket cost of $9250.00 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 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. If you use a standard pharmacy or standard mail order, copays start at $2 for Tier 1 drugs and $12 for Tier 2 drugs. Higher-tier medications require coinsurance instead of flat copays. Tier 3 preferred brand drugs have a 24% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs require a 25% coinsurance. These coinsurance rates apply regardless of whether you use preferred or standard pharmacies, or mail order services.
Additional Benefits
The Aetna Medicare Prime (HMO-POS) plan offers comprehensive medical coverage with predictable out-of-pocket costs, featuring no coinsurance for many of its core services. Inpatient hospital stays require a $380 daily copay for the first six days and no copay thereafter, while primary care visits have a low $5 copay and specialist visits range from no copay to a $30 copay. Emergency care is covered with a $115 copay, which is waived upon admission, and urgent care visits require a $40 copay. This plan also includes valuable supplemental benefits, such as routine vision and dental care with no copay or coinsurance up to specified plan limits. Hearing exams and prescription hearing aids are partially covered with no coinsurance, though hearing aid copays can range up to $1,700. Additionally, home health services and home infusions are available with no copay, while diagnostic lab services also feature no copay and no coinsurance.
Inpatient Hospital See details
Aetna Medicare Prime (HMO-POS) partially covers inpatient hospital services with no coinsurance, as upgrades and non-Medicare-covered stays are not covered. For covered acute care, there is a $380 daily copay for days 1 through 6 and no copay for days 7 and beyond, while psychiatric care requires a $346 daily copay for days 1 through 6 and no copay for days 7 through 90.
Outpatient Services See details
Outpatient services are covered by Aetna Medicare Prime (HMO-POS) with no coinsurance, featuring copays ranging from $0 to $380 for outpatient hospital services and $380 per stay for observation services. Ambulatory surgical center and blood services have no copay and no coinsurance, while outpatient substance abuse individual and group sessions require a $30 copay.
Partial Hospitalization See details
Aetna Medicare Prime (HMO-POS) covers partial hospitalization services with a copay of either $60.00 or $110.00 and no coinsurance. Prior authorization is required for these covered services.
Ambulance and Transportation Services See details
Aetna Medicare Prime (HMO-POS) covers ground and air ambulance services with a $300 copay and no coinsurance, though prior authorization is required. While transportation is technically covered, some services are covered but transportation to plan-approved health-related locations and any health-related locations is not covered.
Emergency Services See details
Aetna Medicare Prime (HMO-POS) covers emergency services with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services have a $40 copay and no coinsurance, while worldwide emergency services are covered up to $250,000 with no coinsurance and copays of $115 for emergency or urgent care and $300 for emergency transportation.
Primary Care See details
Aetna Medicare Prime (HMO-POS) covers primary care physician services with a $5 copay and specialist visits from no copay to a $30 copay, both with no coinsurance, while chiropractic and podiatry services are not covered. Other services like occupational, physical, mental health, psychiatric, and opioid treatment therapies require copays of $25 to $30 with no coinsurance, whereas telehealth benefits feature a 20% coinsurance and copays up to $40.
Preventive Services See details
Aetna Medicare Prime (HMO-POS) features partially covered preventive services with no copay and no coinsurance for annual physical exams, health education, smoking cessation, fitness benefits, remote access technologies, wigs, and routine screenings, while kidney disease education has no copay and a 20% coinsurance. However, the plan does not cover in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, enhanced disease management, telemonitoring, safety devices, or counseling.
Hearing Services See details
Aetna Medicare Prime (HMO-POS) covers hearing services, including Medicare-covered exams for a $30 copay and no coinsurance, plus annual routine exams and fitting evaluations with no copay or coinsurance. Prescription hearing aids are partially covered with no coinsurance and copays ranging from $0 to $1,700, though inner ear, outer ear, over the ear, and over-the-counter (OTC) hearing aids are not covered.
Vision Services See details
Aetna Medicare Prime (HMO-POS) covers vision services with no coinsurance, offering eye exams with a $0 to $30 copay and routine annual exams with no copay. Covered eyewear, including contacts and eyeglasses, also features no copay and no coinsurance up to a $100 annual maximum benefit.
Dental Services See details
Dental services are partially covered by Aetna Medicare Prime (HMO-POS), offering a $30 copay and no coinsurance for Medicare-covered dental care, and no copay or coinsurance for other preventive and comprehensive services up to a $1,000 annual limit. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Aetna Medicare Prime (HMO-POS) covers home infusion bundled services with no copay, although prior authorization is required. Medicare Part B insulin is covered with a $35 copay and no coinsurance, while chemotherapy and other Part B drugs have a coinsurance ranging from 0% to 20%.
Dialysis Services See details
Dialysis services are covered by Aetna Medicare Prime (HMO-POS) with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
Aetna Medicare Prime (HMO-POS) covers medical equipment, including durable medical equipment, prosthetics, and diabetic supplies, with no copay and prior authorization required. Coinsurance ranges from no coinsurance up to 20% depending on the specific item, with prosthetic devices and diabetic shoes requiring a flat 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Aetna Medicare Prime (HMO-POS) with prior authorization required. Diagnostic tests and procedures have no coinsurance and a $0 to $30 copay, while lab services feature no copay and no coinsurance. Diagnostic radiology copays start at $0, outpatient X-rays require a $30 copay with coinsurance, and therapeutic radiology requires a copay and at least 20% coinsurance.
Home Health Services See details
Home health services are covered by Aetna Medicare Prime (HMO-POS) with no copay and no coinsurance. Prior authorization is required to receive this benefit.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are covered under Aetna Medicare Prime (HMO-POS) with no coinsurance, but only some services are covered as cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
Aetna Medicare Prime (HMO-POS) covers skilled nursing facility (SNF) services with no coinsurance, offering no 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 required, and additional days beyond the standard 100 days are not covered.
Other Services See details
Aetna Medicare Prime (HMO-POS) partially covers other services, providing a meal benefit for chronic illness, annual wellness exams, screening mammography, and additional gFOBT and FIT screenings with no copay and no coinsurance. Acupuncture, over-the-counter (OTC) items, and dual-eligible SNP services are not covered under this plan.
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