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Aetna Medicare Enhanced (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare Enhanced (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Aetna Medicare Enhanced (PPO) in 2026, please refer to our full plan details page.
Aetna Medicare Enhanced (PPO) is a PPO plan offered by CVS Health Corporation available for enrollment in 2025 to people living in Rio Grande Valley and Corpus Christi Counties. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that Aetna Medicare Enhanced (PPO) 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 Enhanced (PPO).
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 Enhanced (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $45.00. 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 $300.00 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 combined Maximum Out-Of-Pocket cost of $10100.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $10100.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
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 Enhanced (PPO) plan features an annual drug deductible of $300 and offers significant savings on generic medications, including no copay for Tier 1 preferred generics at preferred pharmacies and through preferred mail order. Standard pharmacies and standard mail orders charge a low copay starting at $2 for Tier 1 drugs, while Tier 2 generics require a $10 copay at preferred locations and a $12 copay at standard locations for a one-month supply. For higher-tier medications, costs are based on coinsurance, with Tier 3 preferred brands requiring 25% coinsurance and Tier 4 non-preferred drugs requiring 26% coinsurance regardless of pharmacy type. Tier 5 specialty drugs carry a 29% coinsurance for a one-month supply at both preferred and standard pharmacies or mail-order services.
Additional Benefits
The Aetna Medicare Enhanced (PPO) plan offers comprehensive coverage with no copays for primary care visits, routine physicals, and home health services. For hospital stays, members pay no coinsurance, though inpatient acute care requires a $440 daily copay for the first six days and outpatient hospital services range from no copay up to a $275 copay. Emergency care is covered with a $130 copay, which is waived if you are admitted, and urgent care visits require a $50 copay. Specialist visits require a copay of up to $25, while routine hearing and vision exams feature no copays alongside a $275 annual eyewear allowance. Preventive dental cleanings and exams also have no copay, while comprehensive dental services require 20% to 50% coinsurance up to a $1,500 yearly limit. Additionally, medical equipment is covered with no copays and coinsurance ranging up to 20%.
Inpatient Hospital See details
Aetna Medicare Enhanced (PPO) partially covers inpatient hospital services with no coinsurance, requiring a daily copay of $440 for days 1 to 6 of acute care (with no copay for days 7 and beyond) and $325 for days 1 to 6 of psychiatric care (with no copay for days 7 to 90). Unlimited additional acute days are covered with no copay, but additional psychiatric days, hospital upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Aetna Medicare Enhanced (PPO) covers outpatient services with no coinsurance, featuring a $0 to $275 copay for outpatient hospital services and a $440 copay per stay for observation services. Ambulatory surgical center and blood services are covered with no copay and no coinsurance, while outpatient substance abuse services require a $25 copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by Aetna Medicare Enhanced (PPO) 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
Ambulance and transportation services are covered by Aetna Medicare Enhanced (PPO), which requires a $300 copay for ground ambulance services and a 20% coinsurance for air ambulance services, with prior authorization required for both. Some transportation services are covered, but transportation to plan-approved or any health-related locations is not covered.
Emergency Services See details
Aetna Medicare Enhanced (PPO) covers emergency services with a $130 copay, which is waived if admitted to the hospital within 24 hours, and urgently needed services with a $50 copay, both with no coinsurance. Worldwide emergency and urgent services are also covered with a $130 copay, and worldwide emergency transportation is covered with a $300 copay, all featuring no coinsurance up to a maximum plan benefit of $250,000.
Primary Care See details
Primary care benefits under Aetna Medicare Enhanced (PPO) feature no copay and no coinsurance for primary care physician visits, while specialist visits, therapy, and mental health services require copays up to $25 with no coinsurance. Telehealth services are available with a $0 to $50 copay and 20% coinsurance, but podiatry and chiropractic services are not covered.
Preventive Services See details
Preventive services are partially covered under the Aetna Medicare Enhanced (PPO) plan, with no copay and no coinsurance for annual physicals, fitness benefits, and health education, though kidney disease education requires a 20% coinsurance and no copay. Non-covered sub-services include in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, weight management, alternative therapies, and therapeutic massage. Additionally, adult day health, nutritional/dietary benefits, home-based palliative care, in-home support, caregiver support, enhanced disease management, telemonitoring, home safety devices, and counseling services are not covered.
Hearing Services See details
Hearing services are partially covered by Aetna Medicare Enhanced (PPO), excluding OTC hearing aids as well as inner ear, outer ear, and over-the-ear prescription hearing aids. Medicare-covered exams require a $25 copay and no coinsurance or deductible, while routine exams, fitting evaluations, and covered prescription hearing aids have no copay, coinsurance, or deductible, up to a $500 annual maximum benefit per ear.
Vision Services See details
Vision services are covered by Aetna Medicare Enhanced (PPO) with no copay, no coinsurance, and no deductible for both eye exams and eyewear. The plan includes one routine eye exam per year with a $50 maximum benefit, alongside a $275 combined annual allowance for contacts, eyeglasses, frames, lenses, and upgrades.
Dental Services See details
Aetna Medicare Enhanced (PPO) offers partially covered dental services, with Medicare-covered dental requiring a $25 copay and no coinsurance, and preventive services like exams and cleanings having no copay and no coinsurance. Comprehensive dental services carry no copay and 20% to 50% coinsurance up to a $1,500 yearly limit, but other diagnostic services, fluoride, other preventive services, maxillofacial prosthetics, implants, and orthodontics are not covered.
Home Infusion bundled Services See details
Aetna Medicare Enhanced (PPO) covers home infusion bundled services with no copay, though prior authorization and step therapy are required. Medicare Part B insulin drugs are covered with a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs have a coinsurance ranging from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered by the Aetna Medicare Enhanced (PPO) with no copay and a 20% coinsurance. Prior authorization is required to receive these services.
Medical Equipment See details
Medical equipment is covered by Aetna Medicare Enhanced (PPO) with prior authorization required and features no copays across all categories. Members will pay between no coinsurance and 18% coinsurance for durable medical equipment (DME), and up to 20% coinsurance for prosthetics, medical supplies, and diabetic equipment.
Diagnostic and Radiological Services See details
Aetna Medicare Enhanced (PPO) covers diagnostic and radiological services, which require prior authorization. Lab services have no copay and no coinsurance, while diagnostic tests require a $0 to $50 copay and no coinsurance. Diagnostic radiological services start at a $0 copay, outpatient X-rays have no copay but require coinsurance, and therapeutic radiological services require a copay and a minimum 20% coinsurance.
Home Health Services See details
Aetna Medicare Enhanced (PPO) covers home health services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under the Aetna Medicare Enhanced (PPO) with no copay and no coinsurance, but only some services are covered as standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
Aetna Medicare Enhanced (PPO) covers skilled nursing facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day hospital stay. Covered care requires a $10 copayment for days 1 through 20 and a $218 copayment for days 21 through 100, though additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Aetna Medicare Enhanced (PPO) partially covers other services with no copay and no coinsurance, including an annual wellness exam, additional gFOBT and FIT screenings, and a $30 quarterly reimbursement for over-the-counter items. Acupuncture, meal benefits, and dual eligible SNP services are not covered under this plan.
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