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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 Dallas and Surrounding 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 a $590.00 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:
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Drug Coverage
The Aetna Medicare Prime (HMO) plan has a $590 deductible for prescription drugs. In the initial coverage phase, after you meet your deductible, you'll pay a copay or coinsurance based on the drug tier and pharmacy. For example, preferred generic drugs have no copay at a preferred pharmacy or through mail order, but a $12 copay at a standard pharmacy. For standard generic drugs, preferred brand drugs, and non-preferred drugs, you pay 24% or 25% coinsurance, depending on the drug and pharmacy. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Aetna Medicare Prime (HMO) plan offers comprehensive coverage with a focus on outpatient and preventive services. You'll find no copays for primary care visits, many preventive services, and vision services. The plan also includes coverage for hearing exams, prescription hearing aids, and dental services, along with additional benefits like home health services, and coverage for OTC items. This plan has copays for inpatient hospital stays, emergency services, and specialist visits. Outpatient services, including mental health and substance abuse, are covered with varying copays. There are also cost-sharing requirements for ambulance services, partial hospitalization, and some diagnostic and radiological services.
Inpatient Hospital See details
Inpatient Hospital services are covered, with a copay of $295 per day for days 1-6, and no copay for days 7-90. Inpatient Hospital Psychiatric services are also covered, with a copay of $300 per day for days 1-6, and no copay for days 7-90.
Outpatient Services See details
Outpatient Services are covered, including outpatient hospital services with a copay between $0 and $275, observation services with a $275 copay, ambulatory surgical center services with no copay, and outpatient substance abuse services with a $40 copay for both individual and group sessions. Outpatient blood services are covered with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Aetna Medicare Prime (HMO) plan. You will have a $100 copay for this benefit, and prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Aetna Medicare Prime (HMO) plan. Air ambulance services have a 20% coinsurance, and ground ambulance services have a $270 copay, while 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 by the Aetna Medicare Prime (HMO) plan. Emergency Services have a $140 copay with no coinsurance, and Urgently Needed Services have a $65 copay with no coinsurance. Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $140 copay, and Worldwide Emergency Transportation has a $270 copay, all with no coinsurance.
Primary Care See details
The Aetna Medicare Prime (HMO) plan covers primary care physician services with no copay, chiropractic services with a $20 copay, and occupational therapy services with a $40 copay. Physician specialist services have a copay between $10 and $35, and mental health specialty services have a $35 copay for individual and group sessions. Physical therapy and speech-language pathology services have a $35 copay, and additional telehealth benefits have a 20% coinsurance and a copay between $0 and $65. Opioid treatment program services have a $35 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. It also covers additional preventive services, such as health education, wigs for hair loss, additional sessions of smoking and tobacco cessation counseling, fitness benefits, remote access technologies, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a welcome visit, all with no copay. Kidney disease education services are covered with 20% coinsurance. However, in-home safety assessment, personal emergency response system, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefit, home-based palliative care, in-home support services, and support for caregivers of enrollees are not covered.
Hearing Services See details
Hearing Services include hearing exams and prescription hearing aids. Hearing exams have a $35 copay and routine hearing exams and fitting/evaluation for hearing aids have no copay. Prescription hearing aids are covered up to $500 per year and have no copay for all types of prescription hearing aids except for inner ear, outer ear, and over the ear hearing aids, which are not covered.
Vision Services See details
Vision services include eye exams and eyewear. Eye exams, including routine eye exams and other eye exam services such as follow-up diabetic eye exams, have no copay. Eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades, also have no copay, with a combined maximum plan benefit of $160 per year.
Dental Services See details
The Aetna Medicare Prime (HMO) plan covers Medicare Dental Services with a $35 copay, oral exams and dental x-rays with no copay, and prophylaxis (cleaning) with no copay, but it does not cover fluoride treatments. Orthodontic Services are covered up to a maximum of $2500 per year, while restorative services, adjunctive general services, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are covered with coinsurance between 20% and 50%. Endodontics are covered with a 20% coinsurance, and the plan does not cover maxillofacial prosthetics, implant services, or orthodontics.
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. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Aetna Medicare Prime (HMO) plan, but require prior authorization. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment with 0-20% coinsurance and no copay, Prosthetics/Medical Supplies with coinsurance, and Diabetic Equipment, including Diabetic Supplies with 0-20% coinsurance and Medicare-covered Diabetic Therapeutic Shoes or Inserts with no copay. Durable Medical Equipment for use outside the home is not covered.
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, and lab services with no copay. Radiological services include coverage for diagnostic radiological services with a copay up to $325, therapeutic radiological services with 20% coinsurance, and outpatient X-ray services with no copay.
Home Health Services See details
Home Health Services are covered by the Aetna Medicare Prime (HMO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover the sub-services of Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services. A doctor referral is required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Aetna Medicare Prime (HMO) with prior authorization. For days 1-20, the copay is $20 per day, and for days 21-100, the copay is $214 per day; additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Aetna Medicare Prime (HMO) plan covers Over-the-Counter (OTC) Items with no copay, and a maximum plan benefit coverage amount of $30 every three months. Other services like Acupuncture, Meal Benefit, 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.
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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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