A non-government entity
Aetna Medicare PinnacleHealth Prime (HMO-POS)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare PinnacleHealth 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 PinnacleHealth Prime (HMO-POS) in 2026, please refer to our full plan details page.
Aetna Medicare PinnacleHealth Prime (HMO-POS) is a HMO-POS plan offered by CVS Health Corporation available for enrollment in 2025 to people living in South Central Pennsylvania. This plan received an overall rating of 3 out of 5 stars in 2026.
It's important to know that Aetna Medicare PinnacleHealth 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 PinnacleHealth 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 PinnacleHealth 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 $6900.00 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:
Sign up for Aetna Medicare PinnacleHealth Prime (HMO-POS)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The Aetna Medicare PinnacleHealth Prime (HMO-POS) plan features an annual drug deductible of $615. For Tier 1 preferred generic and Tier 2 generic drugs, you pay no copay when using a preferred pharmacy or preferred mail-order service for any supply length. If you choose a standard pharmacy or standard mail-order service, Tier 1 copays range from $2 to $6, while Tier 2 copays range from $12 to $36. Brand-name and specialty medications on this plan are subject to coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 24% coinsurance across all pharmacy and mail-order options. For Tier 4 non-preferred drugs and Tier 5 specialty drugs, you will pay a 25% coinsurance, with specialty drugs limited to a one-month supply.
Additional Benefits
The Aetna Medicare PinnacleHealth Prime (HMO-POS) plan offers comprehensive medical coverage with no copay for primary care visits, annual physicals, and fitness benefits. For inpatient hospital stays, members pay a $425 copay per stay with no coinsurance, while outpatient hospital services require a copay ranging from $0 to $250. Emergency room visits carry a $115 copay, which is waived upon hospital admission, and specialist visits require a low copay of $0 to $30. Supplemental coverage includes preventive dental care, routine eye exams, and annual hearing fittings with no copay. Additionally, members benefit from a $175 annual eyewear allowance, up to $500 per ear annually for hearing aids, and a $45 quarterly over-the-counter benefit with no copays. Skilled nursing facility care is also covered with no copay for the first 20 days and a $218 daily copay for days 21 through 100.
Inpatient Hospital See details
Aetna Medicare PinnacleHealth Prime (HMO-POS) covers inpatient acute hospital stays with no coinsurance and a $425 copay per stay, while inpatient psychiatric stays have no coinsurance and a $350 daily copay for days 1 through 5 (with no copay for days 6 through 90). Prior authorization is required for these services, and certain sub-services such as upgrades and non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient Services covered by Aetna Medicare PinnacleHealth Prime (HMO-POS) feature no coinsurance across all services, with no copay for ambulatory surgical center and blood services, and a $30 copay for outpatient substance abuse sessions. Outpatient hospital services require a copay ranging from $0 to $250, while observation services have a $250 copay per stay, with prior authorization required for most of these benefits.
Partial Hospitalization See details
Partial hospitalization is covered by Aetna Medicare PinnacleHealth Prime (HMO-POS) with no coinsurance and a copay of either $55.00 or $110.00. Prior authorization is required for these services.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are partially covered by Aetna Medicare PinnacleHealth Prime (HMO-POS), with ground ambulance services requiring a $300 copay and no coinsurance, and air ambulance services requiring a 20% coinsurance and no copay. Prior authorization is required for ambulance services, and transportation services to plan-approved or any health-related locations are not covered.
Emergency Services See details
Emergency services are covered by Aetna Medicare PinnacleHealth Prime (HMO-POS) 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 maximum with no coinsurance and copays of $115 for emergency or urgent care and $300 for emergency transportation.
Primary Care See details
Aetna Medicare PinnacleHealth Prime (HMO-POS) covers primary care physician services with no copay and no coinsurance, while specialist, therapy, psychiatric, and mental health services carry copays of $0 to $30 and no coinsurance. Telehealth services require a $0 to $40 copay and 20% coinsurance, whereas chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive Services are partially covered under Aetna Medicare PinnacleHealth Prime (HMO-POS) with no copay or coinsurance for annual physicals, fitness benefits, and screenings, while kidney disease education requires a 20% coinsurance and no copay. Covered supplemental services like health education and chemotherapy wigs (up to $400 annually) have no copay or coinsurance. Non-covered services include in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, palliative care, in-home support, caregiver support, enhanced disease management, telemonitoring, home safety devices, and counseling.
Hearing Services See details
Hearing services are covered by Aetna Medicare PinnacleHealth Prime (HMO-POS), featuring a $30 copay for Medicare-covered exams and no copay or coinsurance for annual routine exams and fittings. Prescription hearing aids are partially covered with no copay or coinsurance up to $500 per ear yearly, though OTC, inner ear, outer ear, and over-the-ear hearing aids are not covered.
Vision Services See details
Aetna Medicare PinnacleHealth Prime (HMO-POS) covers vision services with no coinsurance, offering eye exams with a $0 to $30 copay and one routine exam per year with no copay. Eyewear, including contacts and eyeglasses, is also covered with no copay up to a combined annual maximum benefit of $175.
Dental Services See details
Dental Services are partially covered by Aetna Medicare PinnacleHealth Prime (HMO-POS), offering preventive care like exams and cleanings with no copay and no coinsurance, and comprehensive care with no copay and 20% to 50% coinsurance up to a $1,250 annual limit. Medicare-covered dental services require a $30 copay and no coinsurance, while fluoride treatments, implants, orthodontics, maxillofacial prosthetics, other diagnostic, and other preventive services are not covered.
Home Infusion bundled Services See details
Aetna Medicare PinnacleHealth Prime (HMO-POS) covers home infusion bundled services with no copay and no coinsurance, though prior authorization and step therapy may apply. Under this plan, Medicare Part B chemotherapy and other drugs carry a 0% to 20% coinsurance and no copay, while Part B insulin is covered with a $35 copay and no coinsurance.
Dialysis Services See details
Aetna Medicare PinnacleHealth Prime (HMO-POS) covers dialysis services with no copay and a 20% coinsurance, although prior authorization is required.
Medical Equipment See details
Aetna Medicare PinnacleHealth 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 are limited to specified manufacturers.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Aetna Medicare PinnacleHealth Prime (HMO-POS), with prior authorization required for these services. Members pay no copay and no coinsurance for lab services, diagnostic procedures, and diagnostic radiological services, while outpatient X-rays require a $15 copay and therapeutic radiological services carry a 20% coinsurance.
Home Health Services See details
Aetna Medicare PinnacleHealth Prime (HMO-POS) covers home health services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under Aetna Medicare PinnacleHealth Prime (HMO-POS) with no copay and no coinsurance, but only some services are covered in practice. Standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) services are not covered.
Skilled Nursing Facility (SNF) See details
Aetna Medicare PinnacleHealth Prime (HMO-POS) covers Skilled Nursing Facility (SNF) services with no coinsurance and does not require a prior three-day hospital stay. Members pay no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, though additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Aetna Medicare PinnacleHealth Prime (HMO-POS) partially covers other services, offering no copay and no coinsurance for over-the-counter items up to $45 every three months, an annual wellness exam and screening mammography, and additional colorectal cancer screenings. Acupuncture and meal benefits are not covered under this plan.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved