A non-government entity
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 Harris County. 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:
Sign up for Aetna Medicare Prime (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 (HMO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you'll pay a copay or coinsurance depending on the drug tier and pharmacy type. For example, preferred generic drugs have a $5 copay at a preferred pharmacy. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs. If you qualify for the low-income subsidy, you may also have reduced costs.
Additional Benefits
The Aetna Medicare Prime (HMO) plan provides comprehensive coverage, including inpatient hospital stays with a copay, outpatient services, and emergency services. You'll have no copay for primary care visits, preventive services, and many dental and vision services. The plan also offers additional benefits such as hearing exams and hearing aids, with a maximum hearing aid benefit of $1250 per year. This plan includes coverage for home health services with no copay, and also covers services like durable medical equipment and diabetic equipment with a coinsurance. Additional benefits include coverage for over-the-counter items, with a maximum of $60 every three months.
Inpatient Hospital See details
The Aetna Medicare Prime (HMO) plan covers inpatient hospital services, including acute and psychiatric care. For inpatient hospital-acute stays, you'll pay a $150 copay for days 1-4, and no copay for days 5-90; for inpatient hospital psychiatric stays, you'll pay a $475 copay for days 1-4, and no copay for days 5-90. Additional days and upgrades for inpatient hospital-acute, and additional days and non-Medicare-covered stays for inpatient hospital psychiatric are not covered.
Outpatient Services See details
Outpatient services include outpatient hospital services with a copay between $0 and $200, observation services with a $200 copay, ambulatory surgical center services with no copay, individual and group sessions for outpatient substance abuse with a $40 copay, and outpatient blood services with no copay.
Partial Hospitalization See details
Aetna Medicare Prime (HMO) covers partial hospitalization with a $100 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Aetna Medicare Prime (HMO) plan. Ground ambulance services have a $270 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 by the Aetna Medicare Prime (HMO) plan. Emergency Services has a $135 copay, Urgently Needed Services has a $60 copay, and Worldwide Emergency Services has a $135 copay for Worldwide Emergency and Urgent Coverage, and a $270 copay for Worldwide Emergency Transportation.
Primary Care See details
The Aetna Medicare Prime (HMO) plan covers primary care physician services with no copay, and chiropractic services with a $20 copay. Occupational therapy services have a $30 copay, while 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, and physical therapy and speech-language pathology services have a $25 copay. Additional telehealth benefits have a 20% coinsurance and a copay between $0 and $60, and opioid treatment program services have a $25 copay.
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, all with no copay. Kidney Disease Education Services are covered with 20% coinsurance. Other preventive services, including Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit, are covered with no copay. In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), 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, Support for Caregivers of Enrollees, Enhanced Disease Management, Telemonitoring Services, Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered.
Hearing Services See details
Hearing exams are covered with a $25 copay and routine hearing exams and fitting/evaluation for hearing aids are covered with no copay. Prescription hearing aids are covered, with a maximum benefit of $1250 per year, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
The Aetna Medicare Prime (HMO) plan covers vision services, including eye exams and eyewear. Eye exams and eyewear have no copay. Eyewear has a combined maximum benefit of $375 per year.
Dental Services See details
Dental services include coverage for Medicare dental services with a $25 copay, oral exams, dental x-rays, prophylaxis (cleaning), restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery with no copay. Fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered. Orthodontic services have a maximum plan benefit of $3500 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered under the Aetna Medicare Prime (HMO) plan. Medicare Part B Insulin Drugs have a $35 copay, while 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 (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a coinsurance between 0% and 20%, and the plan does not cover DME for use outside the home. Prosthetic devices have a 20% coinsurance, and medical supplies have a coinsurance between 0% and 20%. Diabetic supplies have a coinsurance between 0% and 20%, and diabetic therapeutic shoes/inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic and radiological services, with a minimum copay of $0 and a maximum copay of $40 for diagnostic procedures/tests, no copay for lab services, and a copay of at most $250 for diagnostic radiological services. Therapeutic Radiological Services have a coinsurance of at least 20%, while Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by Aetna Medicare Prime (HMO) with no copay and no coinsurance, but additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered with a doctor's referral, but the plan does not cover the services for Medicare-covered Intensive Cardiac Rehabilitation, Medicare-covered Pulmonary Rehabilitation, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD), or Additional Cardiac Rehabilitation Services. The copay information is available in the plan details.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Aetna Medicare Prime (HMO) plan, with prior authorization required. There is no copay for days 1-20, and a $200 copay for days 21-100; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The Aetna Medicare Prime (HMO) plan covers Over-the-Counter (OTC) Items with no copay, up to a maximum of $60 every three months. Other services like acupuncture, meal benefits, and several additional services 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