A non-government entity
Aetna Medicare Prime Care (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare Prime Care (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 Care (HMO) in 2026, please refer to our full plan details page.
Aetna Medicare Prime Care (HMO) is a HMO plan offered by CVS Health Corporation available for enrollment in 2025 to people living in San Antonio. This plan received an overall rating of 4 out of 5 stars in 2026.
It's important to know that Aetna Medicare Prime Care (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 Care (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 Care (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 $300.00 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 $3800.00 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 Prime Care (HMO)
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 Prime Care (HMO) plan features an annual drug deductible of $300. For Tier 1 preferred generic drugs, you pay no copay at preferred pharmacies and preferred mail-order services, while standard pharmacies charge a $2 copay for a one-month supply. Tier 2 generic drugs require a $10 copay for a one-month supply at preferred pharmacies and a $12 copay at standard pharmacies. For higher-tier medications, cost-sharing transitions to coinsurance, starting with a 25% coinsurance for Tier 3 preferred brand drugs across all pharmacy and mail-order options. Tier 4 non-preferred drugs carry a 26% coinsurance, and Tier 5 specialty drugs require a 29% coinsurance for a one-month supply. These structured tier costs help beneficiaries clearly estimate their out-of-pocket prescription expenses under this plan.
Additional Benefits
The Aetna Medicare Prime Care (HMO) plan offers comprehensive medical coverage featuring no copay and no coinsurance for primary care visits, annual physicals, and home health services. For specialist visits, patients can expect a copay ranging from $10 to $40, while inpatient hospital stays require a daily copay of $280 or $300 for the first six days with no coinsurance. Emergency care is covered with a $150 copay, and urgent care visits require a $65 copay. This plan also includes valuable supplemental benefits, such as routine vision and dental preventive care with no copay or coinsurance. Prescription hearing aids are covered with no copay up to $1,500 per ear, and members receive a $100 annual eyewear allowance alongside a $45 quarterly over-the-counter item allowance. Most diagnostic lab work and outpatient X-rays are also available with no copay, making essential wellness services highly affordable.
Inpatient Hospital See details
Aetna Medicare Prime Care (HMO) covers inpatient hospital services with no coinsurance, though prior authorization is required. For acute care, you pay a $280 copay per day for days 1 to 6 and no copay for additional days, while psychiatric care requires a $300 copay per day for days 1 to 6 and no copay for days 7 to 90. Upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Aetna Medicare Prime Care (HMO) covers outpatient services with no coinsurance, offering no copays for ambulatory surgical center and blood services. Outpatient hospital services require a copay between $0 and $275 (with a $225 copay per stay for observation services), while outpatient substance abuse sessions have a $30 copay.
Partial Hospitalization See details
Partial hospitalization is covered by Aetna Medicare Prime Care (HMO) with a copay of either $100.00 or $180.00 and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered under Aetna Medicare Prime Care (HMO), with ground ambulance services requiring a $285 copay and coinsurance, and air ambulance services requiring a copay and 20% coinsurance, both subject to prior authorization. Some transportation services are covered, though trips to plan-approved or general health-related locations are not covered.
Emergency Services See details
Aetna Medicare Prime Care (HMO) covers emergency services with a $150 copay (waived if admitted within 24 hours) and urgent care with a $65 copay, both with no coinsurance. Worldwide emergency, urgent, and transportation services are also covered up to a $250,000 maximum with no coinsurance and copays ranging from $150 to $285.
Primary Care See details
Aetna Medicare Prime Care (HMO) offers primary care doctor visits with no copay and no coinsurance, and specialist visits with a $10 to $40 copay and no coinsurance. Physical, occupational, psychiatric, and mental health services require a $30 copay and no coinsurance, telehealth services have a $0 to $40 copay and 20% coinsurance, and podiatry and chiropractic services are not covered.
Preventive Services See details
Aetna Medicare Prime Care (HMO) partially covers preventive services, offering an annual physical, health education, and select screenings with no copay and no coinsurance. Kidney disease education is covered with no copay and a 20% coinsurance, but several supplemental services—including medical nutrition therapy, weight management, alternative therapies, and in-home support—are not covered.
Hearing Services See details
Hearing Services are partially covered by Aetna Medicare Prime Care (HMO), offering Medicare-covered exams for a $40 copay and no coinsurance, alongside annual routine exams and fitting evaluations with no copay and no coinsurance. Up to two prescription hearing aids are covered each year with no copay and no coinsurance up to a maximum benefit of $1,500 per ear, though OTC, inner ear, outer ear, and over-the-ear models are not covered.
Vision Services See details
Vision services are covered by Aetna Medicare Prime Care (HMO) with no copay, no coinsurance, and no deductible for eye exams and eyewear. This benefit includes one routine eye exam per year and up to a $100 annual combined maximum allowance for eyewear, including contact lenses, eyeglasses, frames, and upgrades.
Dental Services See details
Aetna Medicare Prime Care (HMO) partially covers dental services, providing preventive care like exams and cleanings with no copay and no coinsurance, and comprehensive care like restorative and endodontics with no copay and 20% to 50% coinsurance up to a $3,000 annual limit. Medicare-covered dental services require a $40 copay and no coinsurance, but fluoride, implants, orthodontics, maxillofacial prosthetics, other diagnostic, and other preventive dental services are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Aetna Medicare Prime Care (HMO) with no copay, though prior authorization is required. Under this benefit, Medicare Part B insulin drugs require a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs feature no copay and a coinsurance ranging from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered under the Aetna Medicare Prime Care (HMO) with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
Aetna Medicare Prime Care (HMO) covers medical equipment, including durable medical equipment (DME), prosthetics, medical supplies, and diabetic services, with prior authorization required for most items. Covered DME, medical supplies, and diabetic supplies have no copay and coinsurance ranging from no coinsurance to 20%. Prosthetic devices require a 20% coinsurance and no copay, while diabetic therapeutic shoes and inserts are covered with no copay.
Diagnostic and Radiological Services See details
Aetna Medicare Prime Care (HMO) covers diagnostic and radiological services, offering lab services and outpatient X-rays with no copay, and diagnostic tests with no coinsurance and a $0 to $40 copay. Diagnostic radiological services feature a minimum $0 copay, while therapeutic radiological services require a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered by Aetna Medicare Prime Care (HMO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are partially covered under Aetna Medicare Prime Care (HMO) with no coinsurance and a required referral, although standard cardiac, intensive cardiac, pulmonary, and SET for PAD services are not covered. Covered services require no coinsurance, but copays may vary depending on the specific rehabilitation service.
Skilled Nursing Facility (SNF) See details
Aetna Medicare Prime Care (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring a $20 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 hospital stay is not required, and additional days beyond the standard 100 days are not covered.
Other Services See details
Aetna Medicare Prime Care (HMO) provides partial coverage for other services with no copay and no coinsurance, including an annual wellness exam, screening mammography, additional gFOBT and FIT screenings, and up to $45 every three months for over-the-counter (OTC) items. Acupuncture and meal benefits are not covered.
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