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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 Dallas and Surrounding Counties. 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 $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 $4200.00 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 Care (HMO) prescription drug plan has an annual drug deductible of $615. You will pay no copay for Tier 1 preferred generic and Tier 2 generic drugs when filled through preferred pharmacies or preferred mail-order services. For standard pharmacies and standard mail order, Tier 1 copays start at $2.00 and Tier 2 copays start at $12.00 for a one-month supply. For higher-tier medications, the plan transitions to coinsurance costs instead of flat copays. Tier 3 preferred brand drugs require a 24% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs require a 25% coinsurance. These coinsurance rates apply across all preferred and standard pharmacy and mail-order options, with Tier 5 specialty drugs limited to a one-month supply.
Additional Benefits
The Aetna Medicare Prime Care (HMO) plan offers affordable coverage for core medical needs, featuring no copay for primary care visits and low copays ranging from $10 to $40 for specialists. Emergency care is available with a $150 copay, while inpatient hospital stays require a $375 daily copay for the first six days and no copay thereafter. Additionally, outpatient services like laboratory tests and x-rays are covered with no copay or coinsurance. For supplemental care, members enjoy no copay for routine eye and hearing exams, alongside a $175 annual eyewear allowance and up to $500 yearly per ear for prescription hearing aids. Preventive dental services also feature no copay, while comprehensive dental care is covered up to a $2,000 yearly limit with 20% to 50% coinsurance. Other essential benefits include home health services with no copay and durable medical equipment with coinsurance ranging up to 20%.
Inpatient Hospital See details
Aetna Medicare Prime Care (HMO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $375 daily copay for days 1 through 6 and no copay for days 7 through 90, with prior authorization required. This benefit is partially covered because 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, featuring copays ranging from $0 to $325 for hospital outpatient visits and $375 per stay for observation services. Ambulatory surgical center and outpatient blood services have no copay and no coinsurance, while outpatient substance abuse sessions carry a $35 copay and no coinsurance.
Partial Hospitalization See details
Aetna Medicare Prime Care (HMO) covers partial hospitalization services with a copay of either $100 or $180 and no coinsurance. Prior authorization is required for these covered services.
Ambulance and Transportation Services See details
Ambulance services are covered by Aetna Medicare Prime Care (HMO) with a $295 copay and no coinsurance for ground transport, and a 20% coinsurance with no copay for air transport, with prior authorization required. These ambulance costs are not waived if you are admitted to the hospital, and transportation services to health-related locations are not covered.
Emergency Services See details
Aetna Medicare Prime Care (HMO) covers emergency services with a $150 copay, which is waived if admitted to the hospital within 24 hours, and urgently needed services with a $65 copay, both with no coinsurance. Worldwide emergency, urgent, and transportation services are also covered with no coinsurance and copays ranging from $150 to $295, up to a maximum plan benefit limit of $250,000.
Primary Care See details
Aetna Medicare Prime Care (HMO) provides primary care physician visits with no copay and no coinsurance, and specialist visits with a $10 to $40 copay and no coinsurance. Physical, occupational, speech, and mental health therapies require a $35 copay and no coinsurance, while chiropractic services are only partially covered because routine chiropractic care is excluded. Podiatry services are not covered, but telehealth benefits are available with a $0 to $65 copay and 20% coinsurance.
Preventive Services See details
Preventive Services under Aetna Medicare Prime Care (HMO) are partially covered, featuring no copay and no coinsurance for annual physicals, health education, and glaucoma screenings, while kidney disease education requires a 20% coinsurance and no copay. Several supplemental benefits are not covered under this plan, including in-home safety assessments, personal emergency response systems, medical nutrition therapy, and weight management programs.
Hearing Services See details
Hearing services are covered by Aetna Medicare Prime Care (HMO), featuring Medicare-covered exams for a $40 copay and no coinsurance, alongside annual routine exams and fitting evaluations with no copay and no coinsurance. Prescription hearing aids are partially covered with no copay or coinsurance up to a $500 maximum per ear yearly, but OTC, inner ear, outer ear, and over-the-ear prescription hearing aids are not covered.
Vision Services See details
Aetna Medicare Prime Care (HMO) covers vision services with no copay, no coinsurance, and no deductible for both eye exams and eyewear. Members are covered for one routine eye exam annually and receive a $175 yearly allowance for contact lenses, eyeglasses, frames, and upgrades.
Dental Services See details
Dental services are partially covered by Aetna Medicare Prime Care (HMO), offering preventive care like cleanings and exams with no copay and no coinsurance, while Medicare-covered dental services require a $40 copay and no coinsurance. Comprehensive benefits such as restorative care and periodontics are covered with no copay and 20% to 50% coinsurance up to a $2,000 annual limit, though fluoride, implants, orthodontics, and maxillofacial prosthetics are not covered.
Home Infusion bundled Services See details
Aetna Medicare Prime Care (HMO) covers home infusion bundled services with no copay, though prior authorization is required. Under this benefit, Medicare Part B insulin has a $35 copay and no coinsurance, while Medicare Part B chemotherapy, radiation, and other Part B drugs have a coinsurance of 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, although prior authorization is required.
Medical Equipment See details
Aetna Medicare Prime Care (HMO) covers medical equipment with no copays for durable medical equipment, prosthetics, and diabetic shoes, though coinsurance ranges from no coinsurance to 20% depending on the item. Prior authorization is required for most equipment, and diabetic supplies are limited to specified manufacturers.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Aetna Medicare Prime Care (HMO), featuring no copay for lab services and outpatient X-rays, and a $0 to $40 copay with no coinsurance for diagnostic tests. Therapeutic radiological services require a minimum 20% coinsurance and a copay, with prior authorization and referrals required for various services.
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 covered under the Aetna Medicare Prime Care (HMO) with no coinsurance and a required referral, though only some services are covered in practice. Standard cardiac rehabilitation ($20 copay), intensive cardiac rehabilitation ($20 copay), pulmonary rehabilitation ($15 copay), and SET for PAD services ($25 copay) are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Aetna Medicare Prime Care (HMO) 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, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Aetna Medicare Prime Care (HMO) partially covers other services, offering annual wellness exams, screening mammographies, and additional gFOBT and FIT tests with no copay and no coinsurance. Acupuncture, over-the-counter (OTC) items, and meal benefits are not covered.
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