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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 2026, 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 Clark and Nye Counties. This plan received an overall rating of 3 out of 5 stars in 2026.
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 $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 $2000.00 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 features an annual drug deductible of $615. For Tier 1 preferred generic and Tier 2 generic drugs, members pay no copay when using a preferred pharmacy or preferred mail-order service for up to a three-month supply. If you use a standard pharmacy or standard mail order, Tier 1 copays start at $2 and Tier 2 copays start at $12 for a one-month supply. Higher-tier prescription drugs require coinsurance rather than flat copays under this plan. Members pay a 24% coinsurance for Tier 3 preferred brand drugs, and a 25% coinsurance for Tier 4 non-preferred drugs and Tier 5 specialty drugs, regardless of whether they use preferred or standard pharmacies. Specialty drugs on Tier 5 are limited to a one-month supply.
Additional Benefits
The Aetna Medicare Prime (HMO) plan offers affordable core medical coverage, featuring no copay and no coinsurance for primary care visits, physical therapy, and home health services. Inpatient hospital stays require a $100 daily copay for the first five days with no copay thereafter, while outpatient services range from no copay to a $100 copay. Emergency room visits carry a $150 copay, and specialist visits range from no copay to $20. Routine vision and hearing exams are fully covered with no copay, no coinsurance, and no deductible, with the plan providing a $100 annual eyewear allowance and a $1,000 annual allowance per ear for prescription hearing aids. Preventive dental care is available with no copay, whereas comprehensive dental services and durable medical equipment require no copay with coinsurance ranging up to 50%. Diagnostic procedures, lab tests, and generic X-rays are also highly accessible with no copays and no coinsurance.
Inpatient Hospital See details
Aetna Medicare Prime (HMO) covers inpatient hospital services with no coinsurance, requiring a $100 daily copay for days 1 through 5 and no copay for days 6 through 90 per stay. Unlimited additional days are covered for acute care, though additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient services are covered by Aetna Medicare Prime (HMO) with no coinsurance, including outpatient hospital services with a $0 to $100 copay and observation services with a $100 copay per stay. Patients will pay a $25 copay and no coinsurance for ambulatory surgical center services, a $30 copay and no coinsurance for outpatient substance abuse sessions, and no copay and no coinsurance for outpatient blood services.
Partial Hospitalization See details
Aetna Medicare Prime (HMO) covers partial hospitalization services with a copayment of either $55.00 or $180.00 and no coinsurance. Prior authorization is required for these covered services.
Ambulance and Transportation Services See details
Aetna Medicare Prime (HMO) covers ambulance services with prior authorization, requiring a $315 copay and no coinsurance for ground transport, and a 20% coinsurance and no copay for air transport. Some transportation services are covered, but trips to plan-approved or any health-related locations are not covered.
Emergency Services See details
Aetna Medicare Prime (HMO) covers emergency services with a $150 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $35 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with no coinsurance and copays ranging from $150 to $315, up to a $250,000 plan limit.
Primary Care See details
Primary Care benefits under Aetna Medicare Prime (HMO) offer no copays and no coinsurance for primary care, occupational therapy, and physical therapy, while specialist visits range from a $0 to $20 copay with no coinsurance. Mental health, psychiatric, and opioid treatments carry a $30 copay and no coinsurance, but telehealth services require a $0 to $35 copay and 20% coinsurance. Chiropractic and podiatry services are not covered under these benefits.
Preventive Services See details
Aetna Medicare Prime (HMO) covers essential preventive services, including annual physical exams, health education, and glaucoma screenings, with no copay and no coinsurance, while kidney disease education carries a 20% coinsurance. The benefit is partially covered, as supplemental services such as in-home safety assessments, medical nutrition therapy, and weight management programs are not covered.
Hearing Services See details
Aetna Medicare Prime (HMO) provides hearing services with no copay, no coinsurance, and no deductible, covering annual exams and fitting evaluations. Prescription hearing aids are partially covered with a $1,000 annual maximum per ear, excluding inner ear, outer ear, and over the ear types, while over-the-counter (OTC) hearing aids are not covered.
Vision Services See details
Vision services are covered by Aetna Medicare Prime (HMO) with no copays, no coinsurance, and no deductibles for both exams and eyewear. This coverage includes one routine eye exam each year and a $100 annual maximum allowance for eyewear, including contact lenses, eyeglasses, frames, and upgrades.
Dental Services See details
Aetna Medicare Prime (HMO) provides partially covered dental services, offering preventive care with no copay and no coinsurance, Medicare-covered services for a $20 copay and no coinsurance, and comprehensive care with no copay and 20% to 50% coinsurance. Fluoride treatment, other diagnostic and preventive services, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Aetna Medicare Prime (HMO) covers home infusion bundled services with no copay, though prior authorization and step therapy are required. Under this benefit, Medicare Part B insulin has a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs have no copay and a coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Dialysis Services are covered by Aetna Medicare Prime (HMO) with no copay and a 20% coinsurance, although prior authorization is required.
Medical Equipment See details
Aetna Medicare Prime (HMO) covers medical equipment with no copays and coinsurance ranging from no coinsurance to 20% depending on the specific item. Prior authorization is required for durable medical equipment, prosthetic devices, medical supplies, and diabetic equipment.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Aetna Medicare Prime (HMO) with prior authorization, offering no copays and no coinsurance for diagnostic procedures, lab services, diagnostic radiology, and outpatient X-rays. Therapeutic radiological services are covered with a 20% coinsurance.
Home Health Services See details
Aetna Medicare Prime (HMO) covers home health services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under Aetna Medicare Prime (HMO) with no copay and no coinsurance, but in practice, only some services are covered while cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
Aetna Medicare Prime (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring a $10 daily copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, and while a three-day prior hospital stay is not needed, additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Aetna Medicare Prime (HMO) partially covers other services, offering an annual wellness exam, screening mammography, and additional gFOBT and FIT with no copay and no coinsurance. Acupuncture, over-the-counter (OTC) items, and meal benefits are not covered under this plan.
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