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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 2025, 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 Bexar and Comal counties. This plan received an overall rating of 4 out of 5 stars in 2025.
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 no drug deductible. Your prescription medication coverage will start immediately.
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:
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Drug Coverage
The Aetna Medicare Prime (HMO) plan has an Enhanced Alternative drug benefit. There is no deductible for prescription drugs. In the initial coverage phase, you will 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. After your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The Aetna Medicare Prime (HMO) plan offers a range of benefits with varying cost-sharing. Inpatient hospital stays have a copay, while outpatient services have copays depending on the service. Emergency services have a copay, and ambulance services have a copay or coinsurance. This plan includes no copay for primary care, preventive services, vision exams, and many dental services. Hearing aids are covered up to a certain amount annually. The plan also covers home health, diagnostic services, and medical equipment with copays or coinsurance, depending on the service.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you will pay a $150 copay for days 1-4, and no copay for days 5-90, while Inpatient Hospital Psychiatric has a $300 copay for days 1-6, and no copay for days 7-90. Additional Days for Inpatient Hospital-Acute is covered with no copay, while Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute, and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient services are covered by Aetna Medicare Prime (HMO), including outpatient hospital services with a copay between $0 and $275, observation services with a $295 copay, and ambulatory surgical center services with no copay. Individual and group sessions for outpatient substance abuse have a copay between $40 and $40, and outpatient blood services have no copay.
Partial Hospitalization See details
Aetna Medicare Prime (HMO) covers partial hospitalization with a $100 copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the Aetna Medicare Prime (HMO) plan. Ground ambulance services have a $265 copay, while air ambulance services have a 20% coinsurance; transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the Aetna Medicare Prime (HMO) plan. Emergency Services have a $140 copay, while Urgently Needed Services have a $65 copay, and both have no coinsurance. Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $140 copay, and Worldwide Emergency Transportation has a $265 copay, and all three have no coinsurance.
Primary Care See details
The Aetna Medicare Prime (HMO) plan covers primary care physician services with no copay, while chiropractic services have a $20 copay. Occupational therapy services have a $30 copay, and physician specialist services have a copay between $10 and $25. Mental health specialty services and psychiatric services have a $25 copay for individual and group sessions. Physical therapy and speech-language pathology services have a $25 copay, and additional telehealth benefits have a 20% coinsurance with a copay between $0 and $65. Opioid treatment program services also have a $25 copay. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
The Aetna Medicare Prime (HMO) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services include Health Education, Additional Sessions of Smoking and Tobacco Cessation Counseling, Fitness Benefit, Remote Access Technologies, and Wigs for Hair Loss Related to Chemotherapy with no copay, and Kidney Disease Education Services with 20% coinsurance. Other services such as In-Home Safety Assessment, Personal Emergency Response System, Medical Nutrition Therapy, and others are not covered.
Hearing Services See details
The Aetna Medicare Prime (HMO) plan covers hearing exams with a $25 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered, with a plan-specified amount up to $2,000 every year, but not for inner ear, outer ear, or over-the-ear hearing aids, and OTC hearing aids are not covered.
Vision Services See details
The Aetna Medicare Prime (HMO) plan covers vision services, including eye exams, routine eye exams, and other eye exam services with no copay. The plan also covers eyewear such as contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades with no copay, up to a combined maximum of $350 every year.
Dental Services See details
Dental services include Medicare dental services with a $25 copay, oral exams with no copay, dental x-rays with no copay, prophylaxis (cleaning) with no copay, restorative services with 20-50% coinsurance, endodontics with 20% coinsurance, periodontics with 20-50% coinsurance, prosthodontics (removable) with 50% coinsurance, and prosthodontics (fixed) with 50% coinsurance. Oral exams are limited to 4 visits per year, and dental x-rays are limited to 3. Fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered, and orthodontics is subject to a $3,500 annual maximum.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs are also covered, with coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Aetna Medicare Prime (HMO) plan and require prior authorization. You will pay 20% coinsurance for this benefit.
Medical Equipment See details
Medical Equipment is covered by the Aetna Medicare Prime (HMO) plan. Durable Medical Equipment has a coinsurance of 0% to 20%, while Durable Medical Equipment for use outside the home is not covered. Prosthetic devices have a 20% coinsurance, and medical supplies have a coinsurance between 0% and 20%. Diabetic Equipment has a coinsurance of 0% to 20% and a copay, depending on the service, with diabetic therapeutic shoes/inserts having no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services, diagnostic procedures/tests with a copay between $0 and $40, lab services with no copay, and outpatient X-ray services with no copay. Diagnostic radiological services have a copay of at most $325, and therapeutic radiological services have a coinsurance of at least 20%.
Home Health Services See details
Home Health Services are covered by the Aetna Medicare Prime (HMO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered with a doctor referral, but the plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. There is a copay for some services, but the specific amount is not provided.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Aetna Medicare Prime (HMO) plan, but require prior authorization. For days 1-20, there is a $20 copay, and for days 21-100, the copay is $214. Additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Under the Aetna Medicare Prime (HMO) plan, acupuncture, meal benefits, dual eligible SNPs with highly integrated services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered. Over-the-counter items and Other 1 and Other 2 services are covered with no copay.
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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.
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