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Aetna Medicare Elite (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare Elite (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Aetna Medicare Elite (HMO) in 2026, please refer to our full plan details page.
Aetna Medicare Elite (HMO) is a HMO plan offered by CVS Health Corporation available for enrollment in 2025 to people living in Northern New Jersey. This plan received an overall rating of 4 out of 5 stars in 2026.
It's important to know that Aetna Medicare Elite (HMO) 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 (HMO).
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 (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $15.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $2.00. You must continue to pay paying your reduced 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 Elite (HMO) plan features an annual drug deductible of $615. For Tier 1 preferred generic and Tier 2 generic medications, you will enjoy no copay when filling prescriptions through preferred pharmacies or preferred mail-order services. If you choose standard pharmacies or standard mail order, copays start at $2 for Tier 1 and $12 for Tier 2 for a one-month supply. For higher-tier medications, costs are structured as a percentage of the drug cost 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 across all pharmacy and mail-order options.
Additional Benefits
The Aetna Medicare Elite (HMO) plan offers comprehensive medical coverage with predictable out-of-pocket costs, featuring no copay and no coinsurance for primary care visits and no copay to a $40 copay for specialists. If you require hospital care, inpatient stays feature no coinsurance, with acute care requiring a $330 copay for the first six days and no copay for remaining days. Emergency room visits have a $115 copay which is waived upon admission, while urgently needed services require a $40 copay, both with no coinsurance. For routine wellness, the plan provides preventive dental, routine hearing, and annual eye exams with no copay and no deductibles. You also receive a $150 annual allowance for eyewear, while Medicare-covered dental and hearing exams require a $40 copay. Additionally, essential services like home health care feature no copay, while durable medical equipment and diagnostic services are covered with no copay to a $40 copay and up to 20% coinsurance.
Inpatient Hospital See details
Aetna Medicare Elite (HMO) covers inpatient hospital services with no coinsurance, though prior authorization is required and non-Medicare-covered stays and upgrades are not covered. For acute care, there is a $330 copay for days 1 through 6 and no copay for days 7 through 90, while psychiatric care requires a $346 copay for days 1 through 6 and no copay for days 7 through 90.
Outpatient Services See details
Aetna Medicare Elite (HMO) covers outpatient services with no coinsurance, featuring outpatient hospital copays from $0 to $350 and observation services at a $330 copay per stay. Ambulatory surgical center and outpatient blood services are covered with no copays or coinsurance, while outpatient substance abuse individual and group sessions require a $40 copay.
Partial Hospitalization See details
Aetna Medicare Elite (HMO) covers partial hospitalization services with no coinsurance, though a copay of either $60.00 or $110.00 applies and prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and transportation services are partially covered by Aetna Medicare Elite (HMO). Ground and air ambulance services require prior authorization and have a $300 copay and no coinsurance, while transportation services to plan-approved or other health-related locations are not covered.
Emergency Services See details
Aetna Medicare Elite (HMO) 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 require a $40 copay and no coinsurance, while worldwide emergency services are covered up to a $250,000 limit with no coinsurance and copays ranging from $115 to $300 depending on the service.
Primary Care See details
Primary care services under the Aetna Medicare Elite (HMO) plan feature no copay and no coinsurance for primary care visits, and a $0 to $40 copay with no coinsurance for specialists. Physical, occupational, and mental health therapies require a $25 to $40 copay with no coinsurance, while telehealth has a $0 to $40 copay and 20% coinsurance; podiatry and chiropractic services are not covered.
Preventive Services See details
Aetna Medicare Elite (HMO) offers partially covered preventive services with no copay and no coinsurance for annual physical exams, various screenings, and select supplemental benefits like health education and fitness. Kidney disease education is covered with no copay but carries a 20% coinsurance, while several supplemental services such as nutritional therapy, weight management, and personal emergency response systems are not covered.
Hearing Services See details
Hearing services are partially covered by Aetna Medicare Elite (HMO) with no deductibles or coinsurance, featuring a $40 copay for Medicare-covered exams and no copay for annual routine exams and fitting evaluations. While prescription hearing aids are covered with copays ranging from $0 to $1,700 and no coinsurance, OTC hearing aids as well as 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 Elite (HMO) with no deductibles and no coinsurance, featuring eye exams with a copay of up to $40, including one annual routine exam with no copay. Eyewear, including contacts and eyeglasses, is covered with no copay up to a combined maximum plan benefit of $150 per year.
Dental Services See details
Aetna Medicare Elite (HMO) partially covers dental services, offering Medicare-covered dental care for a $40 copay and no coinsurance, alongside preventive services like select exams, cleanings, and X-rays with no copay and no coinsurance. However, several services are not covered under this plan, including fluoride, orthodontics, restorative services, endodontics, periodontics, prosthodontics, implants, and oral surgery.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Aetna Medicare Elite (HMO) with no copay, though prior authorization is required. Under this benefit, Medicare Part B insulin drugs require a $35 copay and no coinsurance, while Medicare Part B chemotherapy, radiation, and other Part B drugs have a coinsurance of 0% to 20%.
Dialysis Services See details
Aetna Medicare Elite (HMO) covers Dialysis Services with no copay and a 20% coinsurance, though prior authorization is required for these services.
Medical Equipment See details
Aetna Medicare Elite (HMO) covers medical equipment, including durable medical equipment, prosthetics, and diabetic supplies, with no copay for all covered services. Depending on the specific item, members will pay between no coinsurance and 20% coinsurance, and prior authorization is required.
Diagnostic and Radiological Services See details
Aetna Medicare Elite (HMO) covers diagnostic services with no coinsurance, featuring no copay for lab services and a $0 to $40 copay for diagnostic procedures. Radiological services are also covered, requiring prior authorization and featuring a $0 minimum copay for diagnostic radiology, a $40 copay for outpatient X-rays, and a minimum 20% coinsurance for therapeutic radiology.
Home Health Services See details
Home Health Services are covered by Aetna Medicare Elite (HMO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Aetna Medicare Elite (HMO) covers some cardiac rehabilitation services with no coinsurance, though cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered. For covered services, members will pay no coinsurance, but copayments may apply depending on the specific therapy received.
Skilled Nursing Facility (SNF) See details
Aetna Medicare Elite (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance and requires prior authorization, with no prior three-day hospital stay required. There is no copay for days 1 through 20, a $218 copay for days 21 through 100, and additional days beyond the standard Medicare benefit are not covered.
Other Services See details
Aetna Medicare Elite (HMO) partially covers other services, providing a meal benefit for chronic illness, annual wellness exams, screening mammographies, 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.
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