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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 2025, 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 3.5 out of 5 stars in 2025.
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 $590.00 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:
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Drug Coverage
The Aetna Medicare PinnacleHealth Prime (HMO-POS) plan has an Enhanced Alternative drug benefit. The plan has a deductible of $590.00. In the initial coverage phase, after the deductible, you will pay either a copay or coinsurance depending on the drug tier and pharmacy. Preferred Generic drugs have no copay at preferred pharmacies and mail order, and a $12 copay at standard pharmacies. Standard Generic, Preferred Brand, and Non-Preferred drugs all have a 24% or 25% coinsurance.
Additional Benefits
The Aetna Medicare PinnacleHealth Prime (HMO-POS) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay, while outpatient services, including substance abuse and blood services, have copays. Emergency services and primary care have copays, and preventive services and dental services are available with no copay. The plan also covers hearing, vision, and home infusion services, as well as medical equipment and diagnostic services with varying copays and coinsurance. Skilled nursing facility stays have copays, and additional benefits include over-the-counter items, and meal benefits with no copay.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, with a $425 copay per admission or stay for Inpatient Hospital-Acute. Inpatient Hospital Psychiatric has a $350 copay for days 1-5, and no copay for days 6-90.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services with a copay between $0 and $250, observation services with a $250 copay, ambulatory surgical center services with no copay, outpatient substance abuse services with a $30 copay for both individual and group sessions, and outpatient blood services with no copay. Prior authorization is required for all services.
Partial Hospitalization See details
Aetna Medicare PinnacleHealth Prime (HMO-POS) covers partial hospitalization with a $55 copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required for all ambulance services. Ground ambulance services have a $260 copay, while air ambulance services have a 20% coinsurance. Transportation services to health-related locations are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered. Emergency Services and Worldwide Emergency Coverage and Urgent Coverage have a $110 copay, while Worldwide Emergency Transportation has a $260 copay; there is no coinsurance for any of these services.
Primary Care See details
The Aetna Medicare PinnacleHealth Prime (HMO-POS) plan covers primary care physician services with no copay. Chiropractic services have a $15 copay for routine care, while occupational therapy services have a $30 copay. Physician specialist services have a copay between $0 and $35, and mental health specialty services have a $30 copay for individual and group sessions. Other health care professionals have a copay between $0 and $35, while physical therapy and speech-language pathology services have a $30 copay. Additional telehealth benefits have a 20% coinsurance and a copay between $0 and $45. Opioid treatment program services have a $30 copay.
Preventive Services See details
Preventive Services include Medicare-covered services with no copay, as well as an annual physical exam with no copay. Additional preventive services include Health Education, Nutritional/Dietary Benefit, Additional Sessions of Smoking and Tobacco Cessation Counseling, Fitness Benefit, and Remote Access Technologies, all with no copay, and Wigs for Hair Loss Related to Chemotherapy with no copay and a maximum benefit coverage of $400 per year. Kidney Disease Education Services have a 20% coinsurance. Other preventive services like Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit all have no copay.
Hearing Services See details
Hearing exams are covered with a $35 copay, and routine hearing exams and fitting/evaluation for hearing aids have no copay. Prescription hearing aids (all types) are covered with no copay, but inner ear, outer ear, and over the ear hearing aids are not covered, and OTC hearing aids are not covered. The plan covers a maximum of $500 per year for hearing aids.
Vision Services See details
Vision services are covered, including eye exams and eyewear. Eye exams have a copay of $0-$35, and routine eye exams have a copay of $0. Eyewear, including contact lenses, eyeglasses, eyeglass lenses, eyeglass frames, and upgrades, have a copay of $0 and a combined maximum plan benefit of $325 per year.
Dental Services See details
Dental services are covered, including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery, all with no copay. Medicare Dental Services have a $35 copay and require prior authorization, and orthodontic services are limited to a $3,000 annual maximum. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered, but require prior authorization. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 0% to 20% coinsurance and Prosthetic Devices with 20% coinsurance. Diabetic Supplies have 0% to 20% coinsurance, and Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for Diagnostic Procedures/Tests, Lab Services, Diagnostic Radiological Services, Therapeutic Radiological Services, and Outpatient X-Ray Services. Diagnostic Procedures/Tests have a copay between $0 and $10, while Lab Services have no copay. Diagnostic Radiological Services have a maximum copay of $225, Therapeutic Radiological Services have a coinsurance of at least 20%, and Outpatient X-Ray Services have a $15 copay.
Home Health Services See details
Home Health Services are covered by the Aetna Medicare PinnacleHealth Prime (HMO-POS) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the Aetna Medicare PinnacleHealth Prime (HMO-POS) plan, but the specific services are not covered. There is a copay for Cardiac and Pulmonary Rehabilitation Services, but the specific amount is not provided.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Aetna Medicare PinnacleHealth Prime (HMO-POS) plan. There is no copay for days 1-20, and a $214 copay for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) items, with no copay, and a $90 benefit every three months, and Meal Benefits with no copay. Acupuncture, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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