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Aetna Medicare Prime (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare Prime (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Aetna Medicare Prime (HMO) in 2026, please refer to our full plan details page.
Aetna Medicare Prime (HMO) is a HMO plan offered by CVS Health Corporation available for enrollment in 2025 to people living in Richmond 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 Prime (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 Prime (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 Prime (HMO), 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 $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 Prime (HMO) plan features an annual prescription drug deductible of $615. For Tier 1 preferred generic and Tier 2 generic drugs, you will pay no copay when using a preferred pharmacy or preferred mail-order service. If you use standard pharmacies or standard mail order, Tier 1 copays range from $2 to $6, and Tier 2 copays range from $12 to $36 depending on the supply. Higher-tier medications are subject to coinsurance rather than set copayments. Tier 3 preferred brand drugs require a 24% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs incur a 25% coinsurance. These coinsurance rates remain consistent whether you utilize preferred, standard, or mail-order pharmacy services.
Additional Benefits
Aetna Medicare Prime (HMO) provides comprehensive coverage for core medical needs, featuring no copays and no coinsurance for primary care visits, annual physicals, and home health services. Specialists, urgent care, and emergency services are accessible with low-to-moderate copays and no coinsurance, though inpatient hospital stays require a daily copayment for the first eight days. Diagnostic lab services and preventive screenings are also covered with no copays, helping you manage your health affordably. This plan also includes key ancillary benefits, offering routine dental cleanings, routine eye exams, and annual hearing evaluations with no copays or coinsurance. Additionally, members receive annual allowances for prescription hearing aids and eyewear with no copays, while durable medical equipment and dialysis services are covered with no copays and coinsurance up to 20 percent. However, please note that routine transportation, over-the-counter items, and meal benefits are not covered under this plan.
Inpatient Hospital See details
Inpatient hospital care is covered by Aetna Medicare Prime (HMO) with no coinsurance, though prior authorization is required. For acute stays, there is a $382 copay for days 1 through 8 and no copay for days 9 and beyond, while psychiatric stays require a $292 copay for days 1 through 8 and no copay for days 9 through 90. Non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Aetna Medicare Prime (HMO) covers outpatient services with no coinsurance, though copays and prior authorization requirements vary depending on the service. Patients will pay a $0 to $382 copay for outpatient hospital services, $382 per stay for observation services, and $40 per session for outpatient substance abuse services, while ambulatory surgical center and blood services have no copays.
Partial Hospitalization See details
Partial hospitalization is covered by Aetna Medicare Prime (HMO) with a copay of either $110.00 or $145.00 and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
Ambulance services are covered by Aetna Medicare Prime (HMO) with a $275 copay and no coinsurance for ground transportation, and no copay and 20% coinsurance for air transportation, with prior authorization required. Transportation services to plan-approved or health-related locations are not covered.
Emergency Services See details
Aetna Medicare Prime (HMO) covers emergency services with a $130 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 24 hours. Urgently needed services have a $50 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with no coinsurance and copays ranging from $130 to $275, up to a maximum plan benefit of $250,000.
Primary Care See details
Aetna Medicare Prime (HMO) offers primary care physician visits with no copay and no coinsurance, while specialist visits range from a $0 to $50 copay with no coinsurance. Physical, speech, and occupational therapies require a $50 copay with no coinsurance, whereas podiatry is not covered, and chiropractic has some services covered but routine and other chiropractic services are not covered. Mental health, psychiatric, and opioid treatments carry a $40 copay with no coinsurance, and telehealth benefits are available with a $0 to $50 copay and 20% coinsurance.
Preventive Services See details
Aetna Medicare Prime (HMO) covers preventive services with no copay and no coinsurance for annual physicals, fitness benefits, and screenings, though kidney disease education requires a 20% coinsurance with no copay. Additional preventive benefits are partially covered, excluding 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/dietary benefits, home-based palliative care, in-home support, caregiver support, enhanced disease management, telemonitoring, home safety devices, and counseling.
Hearing Services See details
Aetna Medicare Prime (HMO) covers routine hearing exams and fitting evaluations once per year with no copay or coinsurance, while Medicare-covered exams require a $50 copay and no coinsurance. Prescription hearing aids are partially covered with no copay or coinsurance up to a $500 maximum per ear annually, but OTC hearing aids as well as inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
Vision services are covered by Aetna Medicare Prime (HMO) with no deductible and no coinsurance, featuring routine eye exams with no copay and Medicare-covered exams with a $0 to $50 copay. Eyewear, including lenses, frames, and contacts, is also covered with no copay and no coinsurance up to a $100 annual limit.
Dental Services See details
Dental services are partially covered under the Aetna Medicare Prime (HMO) plan, with Medicare-covered dental services requiring a $50 copay and no coinsurance. Preventive care like oral exams, cleanings, and dental X-rays is available with no copay and no coinsurance, but fluoride, restorative services, endodontics, periodontics, prosthodontics, implants, oral surgery, and orthodontics are not covered.
Home Infusion bundled Services See details
Aetna Medicare Prime (HMO) covers home infusion bundled services 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 require no copay and a coinsurance ranging from 0% to 20%.
Dialysis Services See details
Aetna Medicare Prime (HMO) covers Dialysis Services with no copay and a 20% coinsurance. Prior authorization is required for these covered services.
Medical Equipment See details
Medical equipment is covered by Aetna Medicare Prime (HMO) with no copays and coinsurance ranging from no coinsurance up to 20% for durable medical equipment, prosthetics, and diabetic supplies. Prior authorization is required for these benefits, and diabetic supplies are limited to specified manufacturers.
Diagnostic and Radiological Services See details
Aetna Medicare Prime (HMO) covers diagnostic and radiological services, with prior authorization required for both. Diagnostic procedures and tests have a copay of $0 to $100 with no coinsurance, lab services have no copay and no coinsurance, outpatient X-rays have no copay but require coinsurance, and therapeutic radiological services have a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered by Aetna Medicare Prime (HMO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Aetna Medicare Prime (HMO) provides cardiac rehabilitation services with no coinsurance, and while some services are covered, several specific treatments are not. Specifically, cardiac rehabilitation ($40 copay), intensive cardiac rehabilitation ($40 copay), pulmonary rehabilitation ($15 copay), and supervised exercise therapy for symptomatic peripheral artery disease ($25 copay) are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) care is covered by Aetna Medicare Prime (HMO) with no coinsurance, requiring a daily copayment of $10 for days 1 through 20 and $218 for days 21 through 100. Prior authorization is required, a prior three-day hospital stay is not required, and additional days beyond the standard 100 days are not covered.
Other Services See details
Other services under Aetna Medicare Prime (HMO) are partially covered, offering an annual wellness exam, screening mammography, and additional gFOBT and FIT with no copay and no coinsurance. Acupuncture, over-the-counter (OTC) items, meal benefits, and Dual Eligible SNPs are not covered.
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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.
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