A non-government entity
Aetna Medicare Carilion Health Prime (HMO-POS)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare Carilion Health 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 Carilion Health Prime (HMO-POS) in 2026, please refer to our full plan details page.
Aetna Medicare Carilion Health Prime (HMO-POS) is a HMO-POS plan offered by CVS Health Corporation available for enrollment in 2025 to people living in Roanoke and Surrounding Area. This plan received an overall rating of 3 out of 5 stars in 2026.
It's important to know that Aetna Medicare Carilion Health 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 Carilion Health 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 Carilion Health 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 $500.00 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 $4300.00 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 Carilion Health 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 Carilion Health Prime (HMO-POS) plan features an annual prescription drug deductible of $500. For Tier 1 preferred generic and Tier 2 generic drugs, there is no copay when you fill your prescriptions through preferred pharmacies or preferred mail order services. If you choose to use standard pharmacies or standard mail order, copays for a one-month supply start at $2.00 for Tier 1 drugs and $12.00 for Tier 2 drugs. Brand-name and specialty medications under this plan are covered via coinsurance rather than flat copays. You will pay a 22% coinsurance for Tier 3 preferred brand drugs and a 25% coinsurance for Tier 4 non-preferred drugs across all pharmacy and mail order channels. Specialty tier drugs in Tier 5 require a 27% coinsurance and are limited to a one-month supply.
Additional Benefits
The Aetna Medicare Carilion Health Prime (HMO-POS) plan offers comprehensive medical coverage with low, predictable out-of-pocket costs, including no copay or coinsurance for primary care visits and annual physical exams. Specialist visits have a low copay of $0 to $15, and emergency care is covered with a $130 copay that is waived upon hospital admission. For inpatient hospital stays, members pay a daily copay of $295 for the first six days, followed by no copay for the remaining covered days. Additional benefits feature dental, vision, and hearing services with no copays for routine annual exams. The plan provides a $175 annual allowance for eyewear, up to $1,000 per ear annually for prescription hearing aids, and up to $1,000 in comprehensive dental services with no copay and 20% to 50% coinsurance. Furthermore, members benefit from home health services with no copay and a $30 quarterly allowance for over-the-counter health items.
Inpatient Hospital See details
Aetna Medicare Carilion Health Prime (HMO-POS) covers inpatient hospital services with no coinsurance, requiring a daily copay of $295 for days 1 to 6 for acute stays and $292 for days 1 to 8 for psychiatric stays, followed by no copay for remaining covered days. Prior authorization is required, and upgrades, additional psychiatric days, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Aetna Medicare Carilion Health Prime (HMO-POS) covers outpatient services with no coinsurance, including ambulatory surgical center and blood services with no copay. Outpatient hospital services have a copay between $0 and $295, observation services require a $295 copay per stay, and outpatient substance abuse sessions have a $30 copay, with prior authorization required for most services.
Partial Hospitalization See details
Aetna Medicare Carilion Health Prime (HMO-POS) covers partial hospitalization services with a copayment of either $140.00 or $145.00 and no coinsurance. Prior authorization is required for these covered services.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are partially covered under the Aetna Medicare Carilion Health Prime (HMO-POS) plan, as transportation to plan-approved or any health-related locations is not covered. Prior authorization is required for ambulance services, which cost a $275 copay and no coinsurance for ground transport, or a 20% coinsurance and no copay for air transport.
Emergency Services See details
Aetna Medicare Carilion Health Prime (HMO-POS) covers emergency services with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $25 copay and no coinsurance, while worldwide emergency coverage is available up to a $250,000 lifetime limit with no coinsurance and copays of $130 for emergency or urgent care and $275 for emergency transportation.
Primary Care See details
Primary care benefits under the Aetna Medicare Carilion Health Prime (HMO-POS) plan offer primary care physician visits with no copay and no coinsurance, and specialist visits with a $0 to $15 copay and no coinsurance. Physical, occupational, speech, and podiatry therapies are covered with a $15 copay and no coinsurance, while chiropractic services are not covered. Mental health, psychiatric, and opioid treatment services require prior authorization and a $30 copay with no coinsurance.
Preventive Services See details
Aetna Medicare Carilion Health Prime (HMO-POS) partially covers preventive services, offering an annual physical exam, diabetes self-management, and glaucoma screenings with no copay and no coinsurance. Kidney disease education is covered with no copay and a 20% coinsurance, while several supplemental services such as weight management, personal emergency response systems, and medical nutrition therapy are not covered.
Hearing Services See details
Hearing services are covered by Aetna Medicare Carilion Health Prime (HMO-POS), featuring Medicare-covered exams for a $15 copay and no coinsurance, alongside annual routine exams and fitting evaluations with no copay or coinsurance. Prescription hearing aids are covered up to $1,000 per ear annually with no copay or coinsurance, though OTC hearing aids and inner ear, outer ear, or over-the-ear prescription models are not covered.
Vision Services See details
Vision services are covered by Aetna Medicare Carilion Health Prime (HMO-POS) with no deductibles or coinsurance, featuring one routine eye exam per year with no copay and Medicare-covered exams with a $0 to $15 copay. Eyewear is also covered with no copay up to a combined maximum plan benefit of $175 per year.
Dental Services See details
Dental services are partially covered by Aetna Medicare Carilion Health Prime (HMO-POS), featuring Medicare-covered dental with a $15 copay and no coinsurance, alongside preventive care like cleanings and exams with no copay and no coinsurance. Comprehensive dental services are covered up to a $1,000 annual maximum with no copay and 20% to 50% coinsurance, though other diagnostic services, fluoride, other preventive services, maxillofacial prosthetics, implants, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by Aetna Medicare Carilion Health Prime (HMO-POS) with no copay, though prior authorization is required. Under this benefit, Medicare Part B chemotherapy, radiation, and other drugs require a 0% to 20% coinsurance, while Part B insulin is covered with a $35 copay and no coinsurance.
Dialysis Services See details
Aetna Medicare Carilion Health Prime (HMO-POS) covers Dialysis Services with no copay and a 20% coinsurance. Prior authorization is required to receive these covered services.
Medical Equipment See details
Aetna Medicare Carilion Health Prime (HMO-POS) covers medical equipment, including durable medical equipment, prosthetics, and diabetic supplies, with no copays and coinsurance ranging from no coinsurance to 20%. Prior authorization is required for these benefits, and diabetic supplies are limited to specified manufacturers.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Aetna Medicare Carilion Health Prime (HMO-POS) with prior authorization required. Diagnostic services feature no coinsurance, with no copay for lab services and a $0 to $100 copay for procedures, while radiological services offer no copays for diagnostic and X-ray services and a 20% coinsurance for therapeutic services.
Home Health Services See details
Aetna Medicare Carilion Health Prime (HMO-POS) 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 Carilion Health Prime (HMO-POS) plan with no coinsurance, though only some services are covered in practice. Specific sub-services, including cardiac rehabilitation ($20 copay), intensive cardiac rehabilitation ($20 copay), pulmonary rehabilitation ($15 copay), and SET for PAD rehabilitation ($25 copay), are not covered.
Skilled Nursing Facility (SNF) See details
Aetna Medicare Carilion Health Prime (HMO-POS) covers Skilled Nursing Facility (SNF) services 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, no prior three-day hospital stay is needed, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Other services are partially covered by Aetna Medicare Carilion Health Prime (HMO-POS) with no copay and no coinsurance, including a chronic illness meal benefit, annual wellness exams, screening mammography, additional colorectal screenings, and up to $30 every three months for over-the-counter items. Acupuncture is not covered under this benefit.
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