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Aetna Medicare Advantra Prime Plus (HMO-POS)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare Advantra Prime Plus (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 Advantra Prime Plus (HMO-POS) in 2026, please refer to our full plan details page.
Aetna Medicare Advantra Prime Plus (HMO-POS) is a HMO-POS plan offered by CVS Health Corporation available for enrollment in 2025 to people living in Philadelphia County. This plan received an overall rating of 4 out of 5 stars in 2026.
It's important to know that Aetna Medicare Advantra Prime Plus (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 Advantra Prime Plus (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 Advantra Prime Plus (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 $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 $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 Advantra Prime Plus (HMO-POS) prescription drug coverage features an annual drug deductible of $615. For Tier 1 (Preferred Generic) and Tier 2 (Generic) medications, there is no copay for one, two, or three-month supplies when filled through a preferred pharmacy or preferred mail order. If you use standard pharmacies or standard mail order services, Tier 1 copays start at $2 and Tier 2 copays start at $12 for a one-month supply. For brand-name and specialty drugs, you will pay a percentage of the cost rather than a flat copay. Tier 3 (Preferred Brand) drugs require 24% coinsurance, while Tier 4 (Non-Preferred Drug) and Tier 5 (Specialty Tier) drugs require 25% coinsurance across all pharmacy types. Specialty Tier medications are only available in one-month supplies.
Additional Benefits
The Aetna Medicare Advantra Prime Plus (HMO-POS) plan offers comprehensive medical coverage with predictable cost-sharing, featuring no copays or coinsurance for primary care visits and routine preventive care. For inpatient hospital stays, members pay no coinsurance and a $350 daily copay for the first few days, after which there is no copay. Outpatient services and diagnostic tests are highly affordable, often requiring no coinsurance and low to no copays depending on the specific service. This plan also includes valuable everyday benefits, including routine dental, vision, and hearing exams with no copays, alongside allowances for eyewear and hearing aids. Emergency and urgent care are accessible globally with flat copays and no coinsurance, ensuring peace of mind wherever you travel. While some specialized services like dialysis and medical equipment require a 20% coinsurance, many home health and recovery services are covered with no copay.
Inpatient Hospital See details
Inpatient hospital services are partially covered by Aetna Medicare Advantra Prime Plus (HMO-POS) with no coinsurance, requiring prior authorization and a $350 daily copay for days 1-7 of acute stays and days 1-5 of psychiatric stays, followed by no copay for subsequent days. Upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Aetna Medicare Advantra Prime Plus (HMO-POS) covers outpatient services with no coinsurance, featuring no copays for ambulatory surgical center and outpatient blood services. Outpatient hospital services require a copay of $0 to $350 with no coinsurance, while outpatient substance abuse sessions carry a $45 copay and no coinsurance.
Partial Hospitalization See details
Aetna Medicare Advantra Prime Plus (HMO-POS) covers partial hospitalization services with no coinsurance, though prior authorization is required. Depending on the specific service, you will owe either no copay or a $110 copay.
Ambulance and Transportation Services See details
Ambulance services under Aetna Medicare Advantra Prime Plus (HMO-POS) require prior authorization and carry a $285 copay with no coinsurance for ground transport, and a 20% coinsurance with no copay for air transport. Non-emergency transportation services to plan-approved or health-related locations are not covered under this plan.
Emergency Services See details
Aetna Medicare Advantra Prime Plus (HMO-POS) covers emergency services with a $115 copay (waived if admitted within 24 hours) and urgently needed care with a $40 copay, both with no coinsurance. Worldwide emergency and urgent services are also covered up to a $250,000 maximum with no coinsurance, requiring a $115 copay for emergency or urgent care and a $285 copay for emergency transportation.
Primary Care See details
Primary Care benefits under Aetna Medicare Advantra Prime Plus (HMO-POS) feature no coinsurance and no copay for primary care visits, with specialist, therapy, and mental health services requiring copays between $15 and $45. Chiropractic services are partially covered, as routine chiropractic care is covered with a $15 copay and no coinsurance, but other chiropractic services are not covered.
Preventive Services See details
Preventive services are partially covered by Aetna Medicare Advantra Prime Plus (HMO-POS), offering no copay and no coinsurance for annual physical exams, health education, fitness benefits, and glaucoma screenings, though kidney disease education has no copay and a 20% coinsurance. While supplemental benefits like wigs for chemotherapy hair loss are covered with no copay and no coinsurance up to $400 annually, other services such as in-home safety assessments, personal emergency response systems, weight management, and nutritional benefits are not covered.
Hearing Services See details
Aetna Medicare Advantra Prime Plus (HMO-POS) partially covers hearing services, offering Medicare-covered exams for a $45 copay and no coinsurance, and annual routine exams and fitting evaluations with no copay and no coinsurance. Prescription hearing aids are covered up to $500 per ear annually with no copay and no coinsurance, 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 Advantra Prime Plus (HMO-POS) with no coinsurance, featuring a $0 to $45 copay for eye exams and no copay for annual routine exams. Eyewear, including lenses, frames, and contacts, is also covered with no copay up to a $100 annual maximum.
Dental Services See details
Dental services are partially covered by Aetna Medicare Advantra Prime Plus (HMO-POS), featuring Medicare-covered dental at a $45 copay and no coinsurance, and preventive care like cleanings and exams at no copay and no coinsurance. Comprehensive dental options, including restorative care, endodontics, periodontics, prosthodontics, and oral surgery, are covered with no copay and 20% to 50% coinsurance up to a $500 annual limit, though fluoride, implants, orthodontics, maxillofacial prosthetics, and other diagnostic or preventive services are not covered.
Home Infusion bundled Services See details
Aetna Medicare Advantra Prime Plus (HMO-POS) covers home infusion bundled services with no copay, though prior authorization is 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 0% to 20% coinsurance.
Dialysis Services See details
Aetna Medicare Advantra Prime Plus (HMO-POS) covers dialysis services with no copay and a 20% coinsurance. Prior authorization is required for this covered benefit.
Medical Equipment See details
Medical equipment benefits under Aetna Medicare Advantra Prime Plus (HMO-POS) are covered with no copay, though prior authorization is required. Depending on the equipment, members will pay no coinsurance up to 20% coinsurance for durable medical equipment, medical supplies, and diabetic supplies, or a flat 20% coinsurance for prosthetic devices and diabetic therapeutic shoes.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Aetna Medicare Advantra Prime Plus (HMO-POS), with prior authorization required. Diagnostic procedures, lab services, and diagnostic radiology are offered with no copay and no coinsurance, while outpatient x-rays require a $20 copay and therapeutic radiological services carry a 20% coinsurance.
Home Health Services See details
Aetna Medicare Advantra Prime Plus (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 not covered under Aetna Medicare Advantra Prime Plus (HMO-POS), as none of the individual sub-services, including intensive cardiac, pulmonary, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD), are covered by the plan.
Skilled Nursing Facility (SNF) See details
Aetna Medicare Advantra Prime Plus (HMO-POS) covers Skilled Nursing Facility (SNF) services with no coinsurance, though prior authorization is required and a prior three-day hospital stay is not. There is no copay for days 1 through 20 and a $150 copay for days 21 through 100, but additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other services are partially covered by Aetna Medicare Advantra Prime Plus (HMO-POS) with no copay and no coinsurance, including chronic illness meals, select wellness screenings, and a $25 quarterly over-the-counter item allowance. Acupuncture is not covered under this plan benefit.
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