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Aetna Medicare Enhanced (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare Enhanced (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Aetna Medicare Enhanced (HMO) in 2026, please refer to our full plan details page.
Aetna Medicare Enhanced (HMO) is a HMO plan offered by CVS Health Corporation available for enrollment in 2025 to people living in Nassau and Suffolk Counties. This plan received an overall rating of 3 out of 5 stars in 2026.
It's important to know that Aetna Medicare Enhanced (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 Enhanced (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 Enhanced (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $94.00. 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 Enhanced (HMO) plan features an annual 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 for up to a three-month supply. If you choose a standard pharmacy or standard mail order, your copay ranges from $2 to $6 for Tier 1 drugs and $12 to $36 for Tier 2 drugs depending on the supply duration. For higher-tier medications, the plan transitions from copays to coinsurance across all pharmacy and mail-order options. You will pay a 24% coinsurance for Tier 3 preferred brand drugs, and a 25% coinsurance for Tier 4 non-preferred drugs. Tier 5 specialty drugs also require a 25% coinsurance and are limited to a one-month supply.
Additional Benefits
The Aetna Medicare Enhanced (HMO) plan offers robust coverage with many essential services featuring no copay and no coinsurance, including primary care visits, preventive screenings, and routine dental, vision, and hearing exams. For specialized care, members can expect predictable, low copays ranging up to $45 for specialist visits, diagnostic labs, and physical therapies. Additionally, routine eyewear is covered up to $150 annually with no copay, making everyday health maintenance highly affordable. For more intensive medical needs, the plan utilizes flat copayments rather than coinsurance for most services, such as a $115 copay for emergency room visits and a $395 daily copay for the first six days of an inpatient hospital stay. While home health services and home infusions carry no copay, certain specialized treatments like dialysis, durable medical equipment, and chemotherapy require a coinsurance of up to 20 percent. This combination of no-copay routine care and capped copays for major services provides clear financial predictability for members.
Inpatient Hospital See details
Inpatient hospital services are partially covered by Aetna Medicare Enhanced (HMO) with no coinsurance, requiring a $395 copay for days 1-6 of acute stays and a $339 copay for days 1-6 of psychiatric stays. Both options offer no copay for subsequent days, but upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Aetna Medicare Enhanced (HMO) covers outpatient services with no coinsurance, including ambulatory surgical center and blood services with no copay. Outpatient hospital services range from no copay to a $395 copay (with a $395 copay per stay for observation services), while outpatient substance abuse individual and group sessions require a $45 copay.
Partial Hospitalization See details
Partial hospitalization is covered under Aetna Medicare Enhanced (HMO) with a copay of $105.00 or $110.00 and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
Aetna Medicare Enhanced (HMO) covers ground and air ambulance services with a $280 copay and no coinsurance, subject to prior authorization. While some transportation services are covered, transportation to plan-approved health-related locations and any other health-related locations is not covered.
Emergency Services See details
Aetna Medicare Enhanced (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 are covered with 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 $280.
Primary Care See details
Aetna Medicare Enhanced (HMO) provides primary care physician services with no copay and no coinsurance, while specialist visits range from no copay to a $45 copay with no coinsurance. Physical, occupational, speech, mental health, and psychiatric therapies are covered with copays between $35 and $45 and no coinsurance, but chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive Services under Aetna Medicare Enhanced (HMO) are partially covered, with most covered benefits—including annual physicals, health education, and glaucoma screenings—offered with no copay and no coinsurance. Kidney disease education is covered with no copay and a 20% coinsurance, while several supplemental services, such as in-home safety assessments, weight management programs, and medical nutrition therapy, are not covered.
Hearing Services See details
Hearing services offered by Aetna Medicare Enhanced (HMO) include annual routine exams and fitting evaluations with no copay and no coinsurance, while Medicare-covered exams require a $45 copay and no coinsurance. Prescription hearing aids are partially covered with no coinsurance and a copay of $0 to $1,700 for up to two devices per year, though OTC, inner ear, outer ear, and over-the-ear hearing aids are not covered.
Vision Services See details
Aetna Medicare Enhanced (HMO) covers vision services with no deductibles and no coinsurance, featuring eye exams with a copay of $0 to $45. Routine annual eye exams and eyewear—including contacts, frames, and lenses—have no copay, with eyewear covered up to a combined maximum of $150 per year.
Dental Services See details
Dental services are partially covered by Aetna Medicare Enhanced (HMO), featuring Medicare-covered dental services for a $45.00 copay and no coinsurance, alongside select preventive services like oral exams, cleanings, and X-rays with no copay and no coinsurance. Fluoride, restorative services, endodontics, periodontics, prosthodontics, implants, oral surgery, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Aetna Medicare Enhanced (HMO) with no copay, although prior authorization is required. Under this benefit, Medicare Part B insulin drugs require a $35 copay with no coinsurance, while chemotherapy, radiation, and other Part B drugs carry a coinsurance ranging from 0% to 20%.
Dialysis Services See details
Aetna Medicare Enhanced (HMO) covers Dialysis Services with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
Aetna Medicare Enhanced (HMO) covers medical equipment, durable medical equipment (DME), prosthetics, and diabetic supplies with no copay, though prior authorization is required. Coinsurance for these covered items ranges from no coinsurance up to 20% coinsurance, depending on the specific equipment or supply.
Diagnostic and Radiological Services See details
Aetna Medicare Enhanced (HMO) covers diagnostic and radiological services with prior authorization, featuring no coinsurance and no copay for lab services, and a $0 to $45 copay for diagnostic procedures. Radiological services include diagnostic radiology with no copay, outpatient X-rays with a $45 copay, and therapeutic radiology with a 20% coinsurance.
Home Health Services See details
Home Health Services are covered by Aetna Medicare Enhanced (HMO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services under Aetna Medicare Enhanced (HMO) feature no coinsurance, but only some services are covered in practice. Standard cardiac, intensive cardiac, pulmonary, and SET for PAD services are not covered, which would otherwise carry copays of $15 to $20.
Skilled Nursing Facility (SNF) See details
Aetna Medicare Enhanced (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, featuring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, and while a prior three-day hospital stay is not necessary, additional days beyond the standard 100-day Medicare benefit are not covered.
Other Services See details
Other Services are partially covered by Aetna Medicare Enhanced (HMO), offering chronic illness meal benefits, annual wellness exams, screening mammography, and additional gFOBT and FIT screenings with no copay and no coinsurance. Acupuncture and over-the-counter (OTC) items are not covered under this plan.
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