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Aetna Medicare Prime Care (HMO-POS)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare Prime Care (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 Care (HMO-POS) in 2026, please refer to our full plan details page.
Aetna Medicare Prime Care (HMO-POS) is a HMO-POS plan offered by CVS Health Corporation available for enrollment in 2025 to people living in MI Southeast. This plan received an overall rating of 3 out of 5 stars in 2026.
It's important to know that Aetna Medicare Prime Care (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 Care (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 Care (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 Care (HMO-POS) plan features 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 retail pharmacy or preferred mail-order service. If you use a standard pharmacy or standard mail-order service, Tier 1 copays range from $2 to $6, and Tier 2 copays range from $12 to $36 depending on the supply duration. For higher-tier medications, cost sharing transitions from copays to coinsurance. Tier 3 preferred brand drugs require a 24% coinsurance across all pharmacy types and supply durations. Tier 4 non-preferred drugs and Tier 5 specialty drugs carry a 25% coinsurance, with specialty medications limited to a one-month supply.
Additional Benefits
The Aetna Medicare Prime Care (HMO-POS) plan offers comprehensive medical coverage featuring no copay for primary care visits and routine preventive services. Specialist visits, physical therapy, and urgent care require copays ranging from $35 to $50, while emergency room visits have a $130 copay that is waived if you are admitted. Inpatient hospital stays require a $315 daily copay for the first eight days, with no copay for subsequent days. This plan also includes routine dental, vision, and hearing benefits with no copay for annual exams and routine cleanings. Members receive allowances of up to $175 annually for eyewear and up to $500 per ear for prescription hearing aids with no copay. Additionally, home health services and diagnostic lab tests are fully covered with no copay or coinsurance.
Inpatient Hospital See details
Inpatient hospital care is covered by Aetna Medicare Prime Care (HMO-POS) with no coinsurance, though prior authorization is required. For acute stays, there is a $315 daily copay for days 1 through 8 and no copay for days 9 and beyond, while psychiatric stays require a $300 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
Aetna Medicare Prime Care (HMO-POS) covers outpatient hospital services with no coinsurance and a copay ranging from $0 to $315, alongside observation services at a $315 copay per stay. Ambulatory surgical center and outpatient blood services are covered with no copay and no coinsurance, while outpatient substance abuse sessions require a $40 copay and no coinsurance.
Partial Hospitalization See details
Aetna Medicare Prime Care (HMO-POS) covers partial hospitalization services with a copayment of either $85.00 or $145.00 and no coinsurance. Prior authorization is required for these covered benefits.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by Aetna Medicare Prime Care (HMO-POS), which offers ground ambulance services for a $275.00 copay with no coinsurance and air ambulance services for a 20% coinsurance with no copay. Prior authorization is required for all ambulance services, while plan-approved and general health-related transportation services are not covered.
Emergency Services See details
Emergency services are covered by Aetna Medicare Prime Care (HMO-POS) with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed care has a $50 copay with no coinsurance, while worldwide emergency services are covered up to a $250,000 limit with no coinsurance and copays ranging from $130 to $275.
Primary Care See details
Primary care benefits under Aetna Medicare Prime Care (HMO-POS) feature primary care physician visits with no copay and no coinsurance, while specialist visits require a $40 copay and no coinsurance. Physical, occupational, and speech therapy services cost $35 with no coinsurance, chiropractic care is partially covered at $15 with no coinsurance (routine care is not covered), and podiatry is not covered. Mental health, psychiatric, and opioid treatment services require a $40 copay with no coinsurance, while telehealth is available with a $0 to $50 copay and 20% coinsurance.
Preventive Services See details
Preventive Services under Aetna Medicare Prime Care (HMO-POS) are partially covered, with most included services—such as annual physicals, health education, and screenings—offered with no copay and no coinsurance. Kidney disease education is covered with no copay but requires a 20% coinsurance, while several sub-services, including in-home safety assessments, medical nutrition therapy, and weight management programs, are not covered.
Hearing Services See details
Aetna Medicare Prime Care (HMO-POS) covers hearing services, featuring a $40 copay and no coinsurance for Medicare-covered exams, and no copay or coinsurance for annual routine exams and fitting evaluations. Prescription hearing aids are partially covered with no copay or coinsurance up to $500 per ear annually, though OTC, inner ear, outer ear, and over-the-ear hearing aids are not covered.
Vision Services See details
Aetna Medicare Prime Care (HMO-POS) covers vision services with no coinsurance or deductibles, offering eye exams with a $0 to $40 copay, including annual routine exams with no copay. Eyewear, including contacts and eyeglasses, is also covered with no copay up to a combined maximum of $175 every year.
Dental Services See details
Aetna Medicare Prime Care (HMO-POS) provides partially covered dental services with a $40 copay and no coinsurance for Medicare-covered dental, and no copay or coinsurance for routine exams, x-rays, and cleanings. Comprehensive services are covered with no copay and 20% to 50% coinsurance up to a $1,000 annual maximum, though fluoride, implants, orthodontics, maxillofacial prosthetics, and other diagnostic or preventive dental services are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Aetna Medicare Prime Care (HMO-POS) with no copay, though prior authorization is required. Under this benefit, Medicare Part B insulin drugs require a $35 copay and no coinsurance, while chemotherapy and other Part B drugs require a coinsurance ranging from no coinsurance up to 20%.
Dialysis Services See details
Aetna Medicare Prime Care (HMO-POS) covers dialysis services with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
Medical equipment is covered by Aetna Medicare Prime Care (HMO-POS), featuring no copay and no coinsurance to 20% coinsurance for durable medical equipment (DME), medical supplies, and diabetic supplies. Prosthetic devices are covered with no copay and 20% coinsurance, while diabetic therapeutic shoes and inserts have no copay, with prior authorization required for most of these services.
Diagnostic and Radiological Services See details
Aetna Medicare Prime Care (HMO-POS) covers diagnostic and radiological services with prior authorization required. Lab services have no copay or coinsurance, diagnostic tests have no coinsurance and a copay of up to $75, outpatient x-rays require a $10 copay, and therapeutic radiology services require a 20% coinsurance.
Home Health Services See details
Home Health Services are covered by Aetna Medicare Prime Care (HMO-POS) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under Aetna Medicare Prime Care (HMO-POS) with no coinsurance, though in practice, some services are covered while Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and Supervised Exercise Therapy (SET) for symptomatic Peripheral Artery Disease (PAD) are not covered.
Skilled Nursing Facility (SNF) See details
Aetna Medicare Prime Care (HMO-POS) covers Skilled Nursing Facility (SNF) services with no coinsurance and no prior three-day inpatient hospital stay requirement. Covered stays require prior authorization and cost a $10 daily copay for days 1 through 20 and a $218 daily copay for days 21 through 100, with no coverage provided for additional days.
Other Services See details
Other Services are partially covered by Aetna Medicare Prime Care (HMO-POS), featuring no copay and no coinsurance for eligible over-the-counter items up to $20 every three months, annual wellness exams, and screening mammographies. Acupuncture and meal benefits are not covered under this plan.
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