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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 Harris County. 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 $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 features a $300 annual deductible and offers cost-saving benefits for generic medications. For Tier 1 preferred generic drugs, you will pay no copay when using a preferred pharmacy or preferred mail-order service. Tier 2 generic drugs cost as low as a $10 copay for a one-month supply at preferred locations, while standard pharmacies charge a $12 copay. For higher-tier medications, your costs are based on coinsurance rather than set copays. Tier 3 preferred brand drugs require a 25% coinsurance, while Tier 4 non-preferred drugs require a 26% coinsurance across all pharmacy options. Tier 5 specialty drugs are subject to a 29% coinsurance for a one-month supply at both preferred and standard pharmacies.
Additional Benefits
The Aetna Medicare Prime Care (HMO) plan offers robust healthcare coverage with no copays for primary care visits, preventive services, and home health care. For inpatient hospital stays, members pay a $335 daily copay for the first five days and no copay for the remaining days, while emergency room visits carry a $150 copay that is waived if admitted. Outpatient hospital visits range from a $0 to $200 copay, and specialist visits require a low $10 to $30 copay with no coinsurance. This plan also includes valuable supplemental benefits, featuring no copays or coinsurance for routine vision and hearing exams, alongside a $200 annual eyewear allowance and up to $1,000 per ear yearly for prescription hearing aids. Preventive dental care is available with no copay, while comprehensive dental services require a 20% to 50% coinsurance up to a $2,000 yearly limit. Additionally, members receive a $45 quarterly reimbursement for over-the-counter items, though routine transportation is not covered.
Inpatient Hospital See details
Aetna Medicare Prime Care (HMO) covers inpatient acute hospital stays with no coinsurance and a $335 daily copay for days 1 to 5, followed by no copay for remaining days, though upgrades and non-Medicare-covered stays are not covered. Inpatient psychiatric care is also covered with no coinsurance and a $475 daily copay for days 1 to 4, then no copay for days 5 to 90, but additional psychiatric days and non-Medicare-covered stays are not covered.
Outpatient Services See details
Aetna Medicare Prime Care (HMO) covers outpatient services with no coinsurance, including no copays for ambulatory surgical center and outpatient blood services. Outpatient hospital visits require a $0 to $200 copay, outpatient substance abuse sessions carry a $35 copay, and observation services cost a $335 copay per stay.
Partial Hospitalization See details
Aetna Medicare Prime Care (HMO) covers partial hospitalization services with a copay of $175.00 or $180.00 and no coinsurance. Prior authorization is required for these covered services.
Ambulance and Transportation Services See details
Aetna Medicare Prime Care (HMO) covers ambulance services with prior authorization, requiring a $290 copay (no coinsurance) for ground transport and a 20% coinsurance (no copay) for air transport, neither of which are waived if you are admitted to the hospital. Transportation services are not covered under this plan, including trips to plan-approved or any other health-related locations.
Emergency Services See details
Aetna Medicare Prime Care (HMO) covers emergency services with a $150 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours, and urgently needed services with a $65 copay and no coinsurance. Worldwide emergency and urgent services are covered up to a $250,000 maximum with no coinsurance, carrying a $150 copay for emergency or urgent care and a $290 copay for emergency transportation.
Primary Care See details
Aetna Medicare Prime Care (HMO) offers primary care physician services with no copay and no coinsurance, specialist visits for a $10 to $30 copay and no coinsurance, and various physical, mental health, and psychiatric therapies for a $35 copay and no coinsurance. Podiatry is not covered, telehealth services require a $0 to $65 copay and 20% coinsurance, and while some chiropractic services are covered, routine and other chiropractic services are not.
Preventive Services See details
Aetna Medicare Prime Care (HMO) covers preventive services like annual physicals, glaucoma screenings, and diabetes training with no copay and no coinsurance, though kidney disease education requires a referral and has a 20% coinsurance with no copay. Additional preventive services are partially covered with no copay and no coinsurance, excluding in-home safety assessments, PERS, medical nutrition therapy, medication reconciliation, re-admission prevention, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, home-based palliative care, in-home support, caregiver support, disease management, telemonitoring, home safety modifications, and counseling.
Hearing Services See details
Hearing services are partially covered by Aetna Medicare Prime Care (HMO), featuring a $30 copay and no coinsurance for Medicare-covered exams, alongside annual routine exams and fitting evaluations with no copay and no coinsurance. Prescription hearing aids are covered up to $1,000 per ear yearly with no copay and no coinsurance, though OTC hearing aids and inner ear, outer ear, and over-the-ear prescription models are not covered.
Vision Services See details
Aetna Medicare Prime Care (HMO) covers vision services with no copay, no coinsurance, and no deductible for eye exams and eyewear. This coverage includes one routine eye exam per year and a $200 annual maximum benefit 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, exams, and x-rays with no copay and no coinsurance, and Medicare-covered dental services for a $30 copay and no coinsurance. Covered comprehensive services require no copay and 20% to 50% coinsurance up to a $2,000 annual maximum, but other diagnostic dental, fluoride, other preventive services, maxillofacial prosthetics, implants, and orthodontics 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, covered Medicare Part B chemotherapy, radiation, and other drugs carry a 0% to 20% coinsurance, while Medicare Part B insulin is available for a $35 copay with no coinsurance.
Dialysis Services See details
Dialysis Services are covered by 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 equipment, with no copay and coinsurance ranging from no coinsurance up to 20%. Prior authorization is required for these benefits, and diabetic supplies may be limited to specific manufacturers.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Aetna Medicare Prime Care (HMO), with prior authorization and referrals required for certain services. Members will pay no copay and no coinsurance for lab services, a $0 to $40 copay with no coinsurance for diagnostic tests, no copay for diagnostic radiology and X-rays, and a minimum 20% coinsurance for therapeutic radiology.
Home Health Services See details
Home Health Services are covered under the Aetna Medicare Prime Care (HMO) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under Aetna Medicare Prime Care (HMO) with no coinsurance, though a referral is required. While some services are covered, standard cardiac rehabilitation (with a $20 copay), intensive cardiac rehabilitation (with a $20 copay), pulmonary rehabilitation (with a $15 copay), and SET for PAD services (with a $25 copay) are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) care is covered by Aetna Medicare Prime Care (HMO) with no coinsurance, requiring a $20 daily copayment for days 1 through 20 and a $218 daily copayment for days 21 through 100. Prior authorization is required, a prior three-day hospital stay is not 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 with no copay and no coinsurance, including an annual wellness exam, screening mammography, additional gFOBT and FIT screenings, and a $45 quarterly over-the-counter (OTC) reimbursement. Acupuncture, meal benefits, and other additional services are not covered under this plan.
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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.
* 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.
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