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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 Kent, New Castle, Sussex 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 $46.00. 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 $6750.00 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 generics and Tier 2 generics, you will pay no copay when using a preferred pharmacy or preferred mail-order service. If you choose a standard pharmacy or standard mail order, Tier 1 copays range from $2 to $6, while Tier 2 copays range from $12 to $36 depending on the supply duration. For higher-tier medications, the plan transitions to coinsurance costs across all pharmacy and mail-order options. You will pay a 24% coinsurance for Tier 3 preferred brand drugs, and a 25% coinsurance for both Tier 4 non-preferred drugs and Tier 5 specialty drugs. These cost-sharing structures help you estimate your out-of-pocket prescription drug costs with this Aetna Medicare plan.
Additional Benefits
The Aetna Medicare Enhanced (HMO) plan offers comprehensive medical coverage with predictable out-of-pocket costs, featuring no copay and no coinsurance for primary care doctor visits. Specialist office visits range from no copay up to a $30 copay with no coinsurance, while inpatient acute hospital stays require a flat $450 copay per stay. Emergency room care is covered with a $130 copay that is waived if you are admitted within 24 hours, and urgent care visits require a $50 copay. This plan also includes valuable everyday benefits with no deductibles for vision and hearing services, offering no copay for routine annual eye exams, routine hearing exams, and prescription eyewear up to $275 annually. Preventive dental care is available with no copay, while comprehensive dental services require a 20% to 50% coinsurance up to a $1,000 annual limit. Additionally, home health services are covered with no copay, and skilled nursing facility stays require a $10 daily copay for the first 20 days.
Inpatient Hospital See details
Aetna Medicare Enhanced (HMO) covers inpatient acute hospital stays with no coinsurance and a $450 copay per stay, though upgrades and non-Medicare-covered stays are not covered. Inpatient psychiatric hospital stays are also covered with no coinsurance, requiring a $350 daily copay for days 1 through 5 and no copay for days 6 through 90, but additional psychiatric days and non-Medicare-covered stays are not covered.
Outpatient Services See details
Aetna Medicare Enhanced (HMO) covers outpatient services with no coinsurance, featuring no copays for ambulatory surgical center and blood services, and a $30 copay for outpatient substance abuse sessions. Outpatient hospital and observation services have copays ranging from $0 to $300, and prior authorization is required for most of these services.
Partial Hospitalization See details
Aetna Medicare Enhanced (HMO) covers partial hospitalization services with a copay of either $55.00 or $145.00 and no coinsurance. Prior authorization is required for these covered services.
Ambulance and Transportation Services See details
Aetna Medicare Enhanced (HMO) covers ambulance services with prior authorization, requiring a $290 copay and coinsurance for ground transport, and a 20% coinsurance and copay for air transport. Although transportation services are technically covered, trips to plan-approved or any health-related locations are not covered in practice.
Emergency Services See details
Aetna Medicare Enhanced (HMO) covers emergency services with a $130 copay (waived if admitted to the hospital within 24 hours) and urgently needed services with a $50 copay, with no coinsurance for either service. Worldwide emergency and urgent care are covered up to a $250,000 limit with no coinsurance, requiring a $130 copay for care and a $290 copay for emergency transportation.
Primary Care See details
Aetna Medicare Enhanced (HMO) covers primary care physician services with no copay and no coinsurance, and specialist visits with a $0 to $30 copay and no coinsurance. Physical, occupational, psychiatric, and mental health therapies require a $30 copay and no coinsurance, telehealth has a $0 to $50 copay and 20% coinsurance, and chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive services are partially covered under Aetna Medicare Enhanced (HMO), offering no copay and no coinsurance for annual physicals, glaucoma screenings, diabetes training, and select wellness benefits, while kidney disease education requires a 20% coinsurance. Sub-services not covered under this plan include in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, weight management, alternative therapies, therapeutic massage, adult day health, nutritional or dietary benefits, home-based palliative care, in-home support, caregiver support, enhanced disease management, telemonitoring, home and bathroom safety modifications, and counseling.
Hearing Services See details
Hearing services under Aetna Medicare Enhanced (HMO) are partially covered with no deductible and no coinsurance. Medicare-covered exams require a $30 copay, while routine exams, fitting evaluations, and prescription hearing aids have no copay (up to $500 per ear annually), though OTC hearing aids as well as inner ear, outer ear, and over-the-ear prescription 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 $0 to $30 copay, including one annual routine exam with no copay. Eyewear, such as contacts and eyeglasses, is also covered with no copay and no coinsurance up to a combined maximum of $275 per year.
Dental Services See details
Dental services are partially covered by Aetna Medicare Enhanced (HMO), with no coverage for fluoride, implants, orthodontics, maxillofacial prosthetics, other diagnostic dental, and other preventive dental services. Covered preventive care has no copay and no coinsurance, Medicare-covered dental has a $30 copay and no coinsurance, and comprehensive services require no copay and 20% to 50% coinsurance up to a $1,000 annual limit.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Aetna Medicare Enhanced (HMO) with no copay, though prior authorization and step therapy are required. Under this benefit, Medicare Part B insulin drugs have a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs carry a 0% to 20% coinsurance and no copay.
Dialysis Services See details
Dialysis Services are covered by Aetna Medicare Enhanced (HMO) with no copay and a 20% coinsurance. Prior authorization is required to receive these covered services.
Medical Equipment See details
Aetna Medicare Enhanced (HMO) covers medical equipment, including durable medical equipment, prosthetics, and diabetic supplies, with no copays for all services. Coinsurance for these covered benefits ranges from no coinsurance up to 20%, and prior authorization is required.
Diagnostic and Radiological Services See details
Aetna Medicare Enhanced (HMO) covers diagnostic and radiological services, with prior authorization required for these benefits. There is no copay or coinsurance for diagnostic procedures, lab services, and diagnostic radiology, while outpatient X-rays require a $15 copay and therapeutic radiology has a 20% coinsurance.
Home Health Services See details
Aetna Medicare Enhanced (HMO) covers Home Health Services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Aetna Medicare Enhanced (HMO) provides coverage for Cardiac Rehabilitation Services with no copay and no coinsurance, though only some services are covered. Standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for peripheral artery disease (PAD) services are not covered under this plan.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) care is covered by Aetna Medicare Enhanced (HMO) with no coinsurance, requiring a $10 daily copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, a prior three-day inpatient hospital stay is not necessary for admission, and additional days beyond the standard 100-day benefit period are not covered.
Other Services See details
Aetna Medicare Enhanced (HMO) provides partial coverage for other services with no copay and no coinsurance, including chronic illness meal benefits, wellness exams, mammographies, and a $45 quarterly over-the-counter reimbursement. Acupuncture is not covered under this benefit.
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