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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 Maricopa County. 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 $4150.00 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 offers an Enhanced Alternative prescription drug benefit with an annual deductible of $615.00. After meeting this deductible, members pay no copay for Tier 1 preferred generic drugs at preferred pharmacies or through preferred mail order, while standard pharmacies and standard mail options require a $12.00 copay. For other drug tiers, the plan charges a 24% coinsurance for Tier 2 standard generics and a 25% coinsurance for both Tier 3 preferred brands and Tier 4 non-preferred drugs. Once your yearly out-of-pocket drug costs reach $2,100.00, you enter the catastrophic coverage phase and pay nothing for covered Medicare Part D prescription drugs.
Additional Benefits
The Aetna Medicare Prime (HMO) plan offers affordable access to essential medical care, featuring no copay for primary care physician visits, annual physicals, and home health services. For specialized care, members pay a $95 copay for specialist visits and daily copays for inpatient hospital stays, such as $475 per day for the first seven days of acute care. Outpatient services require no coinsurance, with no copay for ambulatory surgical centers and copays up to $475 for outpatient hospital services. This plan also includes valuable supplemental coverage, including routine vision and hearing exams with no copay and no coinsurance. Dental care is partially covered, offering preventive services with no copay and other covered services with coinsurance up to a $500 annual limit. Emergency room visits require a $150 copay, which is waived if you are admitted, while urgently needed care is available with a $50 copay.
Inpatient Hospital See details
Inpatient Hospital benefits are partially covered by Aetna Medicare Prime (HMO), requiring a $475 daily copay for days 1 to 7 of acute care and a $370 daily copay for days 1 to 5 of psychiatric care, with no copay for additional days and no coinsurance. Non-Medicare-covered stays and upgrades for acute care, along with additional days and non-Medicare-covered stays for psychiatric care, are not covered.
Outpatient Services See details
Aetna Medicare Prime (HMO) covers outpatient services with no coinsurance, offering no copay for ambulatory surgical center and outpatient blood services. Other covered services require prior authorization and feature copays ranging from $40 for outpatient substance abuse sessions to up to $475 for outpatient hospital and observation services.
Partial Hospitalization See details
Partial hospitalization benefits are covered by Aetna Medicare Prime (HMO) with a copay ranging from $55.00 to $180.00 and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are partially covered by Aetna Medicare Prime (HMO), as transportation services to plan-approved or any health-related locations are not covered. Covered ground ambulance services require a $275 copay and no coinsurance, while air ambulance services require 20% coinsurance and no copay, with prior authorization required for all ambulance services.
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 are covered with a $50 copay and no coinsurance, while worldwide emergency care and transportation are covered up to $250,000 with copays ranging from $150 to $275.
Primary Care See details
Primary care benefits are offered by Aetna Medicare Prime (HMO) with no copay for primary care physician visits, though podiatry and routine chiropractic services are not covered. Other covered services require copays, including $95 for specialists, $25 for physical and occupational therapy, and $40 for mental health sessions, while telehealth services feature a 20% coinsurance and up to a $95 copay.
Preventive Services See details
Preventive services are partially covered by Aetna Medicare Prime (HMO), offering annual physicals, glaucoma screenings, diabetes training, and fitness benefits with no copay and no coinsurance, while kidney disease education requires a 20% coinsurance and no copay. However, several services are not covered, including in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, disease management, telemonitoring, home modifications, and counseling.
Hearing Services See details
Aetna Medicare Prime (HMO) partially covers hearing services with no copay and no coinsurance for covered routine exams, fitting evaluations, and prescription hearing aids, which feature a $1,000 annual maximum benefit per ear. However, OTC hearing aids, as well as inner ear, outer ear, and over the ear prescription hearing aids, are not covered.
Vision Services See details
Aetna Medicare Prime (HMO) covers vision services with no copay and no coinsurance for both eye exams and eyewear. This includes one routine eye exam per year and a combined annual eyewear allowance of $100 for contact lenses, eyeglasses, frames, and upgrades.
Dental Services See details
Dental services are partially covered by Aetna Medicare Prime (HMO), excluding fluoride treatments, maxillofacial prosthetics, implant services, and orthodontics. Covered preventive services have no copay and no coinsurance, Medicare-covered dental requires a $95 copay and no coinsurance, and other covered dental services have no copay and 20% to 50% coinsurance up to a $500 annual maximum.
Home Infusion bundled Services See details
Aetna Medicare Prime (HMO) covers home infusion bundled services, which require prior authorization. Covered Medicare Part B insulin drugs have 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 20% coinsurance and no copay. Prior authorization is required to receive this benefit.
Medical Equipment See details
Medical equipment benefits are covered by Aetna Medicare Prime (HMO) and generally require prior authorization. Durable medical equipment, medical supplies, and diabetic supplies have no copay and coinsurance ranging from no coinsurance to 20%, while prosthetic devices carry a 20% coinsurance with no copay, and diabetic therapeutic shoes and inserts feature no copay.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Aetna Medicare Prime (HMO), with prior authorization required. Lab services have no copay, diagnostic tests range from no copay to $10, outpatient X-rays carry a $20 copay, diagnostic radiology ranges from no copay to a $200 copay, and therapeutic radiology requires a 20% coinsurance, with no coinsurance applied to other diagnostic services.
Home Health Services See details
Home health services are covered by Aetna Medicare Prime (HMO) with no copay and no coinsurance. Prior authorization is required to receive these services.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered under Aetna Medicare Prime (HMO) with copays and no coinsurance, but in practice only some services are covered. Under this plan, Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered.
Skilled Nursing Facility (SNF) See details
Aetna Medicare Prime (HMO) partially covers Skilled Nursing Facility (SNF) services, though additional days beyond the Medicare-covered limit are not covered. Prior authorization is required, and you will pay a daily copay of $10 for days 1 through 20 and $218 for days 21 through 100, with no coinsurance.
Other Services See details
Aetna Medicare Prime (HMO) partially covers Other Services, providing annual wellness exams, screening mammography, and additional gFOBT and FIT screenings with no copay and no coinsurance. Acupuncture, over-the-counter (OTC) items, meal benefits, and Dual Eligible SNPs with Highly Integrated Services are not covered.
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