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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 2025, 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 3.5 out of 5 stars in 2025.
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 no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $3900.00 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 Carilion Health Prime (HMO-POS) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you'll pay a copay or coinsurance depending on the drug tier and the pharmacy you use. For example, preferred generic drugs have a $5 copay at preferred pharmacies, while standard generic drugs have a 25% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs. However, this plan may have reduced premiums if you qualify for the low-income subsidy (LIS). The plan's formulary details the specific drugs covered.
Additional Benefits
The Aetna Medicare Carilion Health Prime (HMO-POS) plan offers comprehensive coverage with varying costs. Inpatient hospital stays have a copay, and outpatient services range from no copay to $415. Emergency services have a $140 copay, and primary care visits have no copay. Preventive services, including annual physical exams, have no copay, and the plan also covers hearing, vision, and dental services with no copays for many services. Other benefits include home health services with no copay, and a maximum benefit of $45 every three months for over-the-counter items.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute, with a copay of $415 for days 1-8 and no copay for days 9-90. Inpatient Hospital Psychiatric is also covered, with a copay of $318 for days 1-5 and no copay for days 6-90, but additional days and non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services with a copay ranging from $0 to $415, observation services with a $415 copay, ambulatory surgical center services with no copay, outpatient substance abuse services with a $40 copay for both individual and group sessions, and outpatient blood services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Aetna Medicare Carilion Health Prime (HMO-POS) plan, but requires prior authorization. You will pay a $130 copay for this service.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Aetna Medicare Carilion Health Prime (HMO-POS) plan. Ground ambulance services have a $275 copay, while air ambulance services have a 20% coinsurance. Transportation services to plan-approved or any health-related locations are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, Worldwide Emergency Coverage, and Worldwide Urgent Coverage each have a $140 copay, while Worldwide Emergency Transportation has a $275 copay; there is no coinsurance for any of these services. Worldwide Emergency Services has a maximum plan benefit coverage of $250,000.
Primary Care See details
Primary Care Physician Services are covered with no copay. Chiropractic Services have a $20 copay, while Occupational Therapy Services have a $15 copay. Physician Specialist Services have a $15 copay, and Individual and Group Sessions for Mental Health and Psychiatric Specialty Services have a $30 copay. Podiatry Services and Other Health Care Professional services have varying copays, while Physical Therapy and Speech-Language Pathology Services have a $15 copay. Additional Telehealth Benefits have a 20% coinsurance with a copay between $0 and $40, and Opioid Treatment Program Services have a $30 copay.
Preventive Services See details
Preventive services include coverage for annual physical exams with no copay, as well as additional preventive services which may have a copay. Other covered services include health education, wigs for hair loss, nutritional/dietary benefits, additional sessions for smoking cessation, fitness benefits, remote access technologies, home and bathroom safety devices, kidney disease education, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a welcome visit, all of which have no copay.
Hearing Services See details
Hearing Services includes coverage for hearing exams with a $15 copay, routine hearing exams with no copay for 1 visit every year, and fitting/evaluation for hearing aids with no copay for 1 visit every year. Prescription hearing aids (all types) are covered with no copay for 2 visits every year, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams and eyewear. Eye exams have a copay between $0 and $15, while routine eye exams have no copay. Eyewear, including contact lenses, eyeglasses, eyeglass lenses, eyeglass frames, and upgrades, have no copay and a combined maximum benefit of $200 per year.
Dental Services See details
Dental services include coverage for oral exams, dental x-rays, other diagnostic services, cleaning, fluoride treatments, other preventive services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery, all with no copay; however, maxillofacial prosthetics, implant services, and orthodontics are not covered. There is a $15 copay for Medicare dental services, and the plan has a maximum benefit of $2,100 per year for other dental services.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have between 0% and 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the Aetna Medicare Carilion Health Prime (HMO-POS) plan, but require prior authorization. The coinsurance for dialysis services is 20%.
Medical Equipment See details
Medical equipment is covered, including durable medical equipment (DME) with no copay and 0-20% coinsurance, and diabetic supplies with 0-20% coinsurance. Prosthetic devices have 20% coinsurance, and there is no copay. Diabetic therapeutic shoes/inserts have no copay. Durable medical equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
The Aetna Medicare Carilion Health Prime (HMO-POS) plan covers diagnostic and radiological services, including diagnostic procedures/tests with a copay between $0 and $100, and lab services with no copay. Radiological services are also covered, with diagnostic services having a copay of at most $300 and therapeutic services having at least 20% coinsurance; outpatient X-ray services have no copay.
Home Health Services See details
Home Health Services are covered with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Aetna Medicare Carilion Health Prime (HMO-POS) plan. Although the plan covers the benefit, it does not cover any of the sub-services, including Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered with prior authorization required. For days 1-20, there is a $20 copay, and for days 21-100, there is a $214 copay. Additional days beyond Medicare-covered for SNF, and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services include coverage for Over-the-Counter (OTC) Items with no copay and a maximum benefit of $45 every three months, and a Meal Benefit with no copay. Acupuncture and several other services are not covered.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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