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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 IL Chicago. This plan received an overall rating of 3 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 $5900.00 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 features an annual prescription drug deductible of $615. For Tier 1 preferred generics and Tier 2 generics, members enjoy no copay for up to a three-month supply when filling prescriptions through preferred pharmacies or preferred mail-order services. Standard pharmacies and standard mail-order options are also available, with copays starting at $2.00 for Tier 1 and $12.00 for Tier 2 one-month supplies. For higher-tier medications, costs transition to coinsurance. Tier 3 preferred brand drugs require a 24% coinsurance regardless of the pharmacy type or supply duration. Tier 4 non-preferred drugs and Tier 5 specialty drugs both carry a 25% coinsurance, though specialty medications are limited to a one-month supply.
Additional Benefits
The Aetna Medicare Prime (HMO-POS) plan offers comprehensive medical coverage featuring no copay and no coinsurance for primary care visits, annual preventive exams, and home health services. Specialist visits require a $30 copay, while inpatient hospital stays carry a $325 daily copay for the first several days before transitioning to no copay for additional days. Emergency room visits have a $130 copay, which is waived if you are admitted, and urgent care services are available with a $35 copay. Routine dental, vision, and hearing exams are covered with no copay, though comprehensive dental services require a 20% to 50% coinsurance up to a $2,000 annual limit. The plan also includes coverage for prescription hearing aids up to $500 per ear and routine eyewear up to a $100 annual maximum with no copays. Diagnostic lab services and outpatient ambulatory surgical services are also fully covered with no copay or coinsurance.
Inpatient Hospital See details
Aetna Medicare Prime (HMO-POS) covers inpatient hospital services with no coinsurance, though prior authorization is required. For acute stays, there is a $325 daily copay for days 1 through 8 and no copay for additional unlimited days, while psychiatric stays carry a $325 daily copay for days 1 through 7 and no copay for days 8 through 90. Non-Medicare-covered stays, upgrades, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services are covered by Aetna Medicare Prime (HMO-POS) with no coinsurance, featuring no copay for ambulatory surgical center and blood services. Outpatient hospital services require a copay of up to $275, while outpatient substance abuse sessions carry a $40 copay, with no coinsurance required for either service.
Partial Hospitalization See details
Partial hospitalization is covered by Aetna Medicare Prime (HMO-POS) with a copay of either $85.00 or $145.00 and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
Aetna Medicare Prime (HMO-POS) covers ground ambulance services with a $255 copay and no coinsurance, and air ambulance services with a 20% coinsurance and no copay, with prior authorization required for both. Transportation services are not covered under this plan.
Emergency Services See details
Emergency services are covered by Aetna Medicare Prime (HMO-POS) with a $130 copay, which is waived if admitted to the hospital within 24 hours, and no coinsurance. Urgent care is covered with a $35 copay and no coinsurance, while worldwide emergency services are covered up to a $250,000 limit with no coinsurance and copays of $130 for emergency or urgent care and $255 for emergency transportation.
Primary Care See details
Aetna Medicare Prime (HMO-POS) offers primary care physician services with no copay and no coinsurance, and specialist visits with a $30 copay and no coinsurance. While therapy, psychiatric, and mental health services require a $40 copay and no coinsurance, podiatry is not covered, and only some chiropractic services are covered as routine and other chiropractic services are not covered.
Preventive Services See details
Preventive Services are partially covered by Aetna Medicare Prime (HMO-POS), featuring no copay and no coinsurance for annual exams, health education, and screenings, while kidney disease education has a 20% coinsurance and no copay. Uncovered sub-services include 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/dietary benefits, home-based palliative care, in-home support, caregiver support, enhanced disease management, telemonitoring, home safety devices, and counseling.
Hearing Services See details
Hearing services covered by Aetna Medicare Prime (HMO-POS) include Medicare-covered exams for a $30 copay and annual routine exams and fitting evaluations for no copay, with no coinsurance or deductibles. Prescription hearing aids are covered up to $500 per ear annually with no copay or coinsurance, but OTC hearing aids and inner ear, outer ear, and over-the-ear prescription aid types are not covered.
Vision Services See details
Aetna Medicare Prime (HMO-POS) covers vision services with no coinsurance and no deductibles, featuring a $0 to $30 copay for eye exams and no copay for eyewear. Routine eye exams (one per year) and eyewear—including contacts, eyeglasses, and frames—are covered with no copay, with eyewear subject to a $100 annual maximum.
Dental Services See details
Aetna Medicare Prime (HMO-POS) partially covers dental services, excluding other diagnostic dental services, fluoride treatments, other preventive dental services, maxillofacial prosthetics, implant services, and orthodontics. Medicare-covered dental requires a $30 copay and no coinsurance, while preventive services have no copay and no coinsurance, and comprehensive services feature no copay and 20% to 50% coinsurance up to a $2,000 annual maximum.
Home Infusion bundled Services See details
Aetna Medicare Prime (HMO-POS) covers home infusion bundled services with no copay, though prior authorization is required. Under this benefit, Medicare Part B chemotherapy and other drugs require no copay and 0% to 20% coinsurance, while Part B insulin is covered with a $35 copay and no coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Aetna Medicare Prime (HMO-POS) plan with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
Aetna Medicare Prime (HMO-POS) covers medical equipment, including durable medical equipment, prosthetics, and diabetic supplies, with no copays and coinsurance ranging from 0% to 20%. Prior authorization is required for these services, and diabetic supplies may be limited to specified manufacturers.
Diagnostic and Radiological Services See details
Aetna Medicare Prime (HMO-POS) covers diagnostic services with no coinsurance, offering lab services with no copay and diagnostic tests with a copay between $0 and $95. Covered radiological services require prior authorization and include diagnostic radiology with no copay, outpatient X-rays with a $20 copay, and therapeutic radiology with a minimum 20% coinsurance.
Home Health Services See details
Home health services are covered under the Aetna Medicare Prime (HMO-POS) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Aetna Medicare Prime (HMO-POS) covers Cardiac Rehabilitation Services with no coinsurance, though only some services are covered in practice. Standard cardiac rehabilitation ($20 copay), intensive cardiac rehabilitation ($20 copay), pulmonary rehabilitation ($15 copay), and SET for PAD services ($25 copay) are not covered.
Skilled Nursing Facility (SNF) See details
Aetna Medicare Prime (HMO-POS) covers Skilled Nursing Facility (SNF) services 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, and additional days beyond the standard Medicare-covered 100 days are not covered.
Other Services See details
Other services are partially covered by Aetna Medicare Prime (HMO-POS), with covered benefits like annual wellness exams, screening mammographies, and additional gFOBT and FIT requiring no copay and no coinsurance. Acupuncture, over-the-counter (OTC) items, and meal benefits are not covered.
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