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Aetna Medicare Premier (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare Premier (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Aetna Medicare Premier (PPO) in 2025, please refer to our full plan details page.
Aetna Medicare Premier (PPO) is a PPO plan offered by CVS Health Corporation available for enrollment in 2025 to people living in Central Upstate NY 1. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Aetna Medicare Premier (PPO) 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 Premier (PPO).
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 Premier (PPO), 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 $590.00 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 combined Maximum Out-Of-Pocket cost of $14000.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $14000.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
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 Premier (PPO)
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Drug Coverage
The Aetna Medicare Premier (PPO) plan has an enhanced alternative drug benefit. The plan has a $590 deductible. After the deductible, you will pay a copay or coinsurance depending on the drug tier and the pharmacy you use. For example, preferred generic drugs have no copay at preferred pharmacies or mail order, but have a $12 copay at standard pharmacies. After your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The Aetna Medicare Premier (PPO) plan offers comprehensive coverage with a variety of benefits. You'll find no copays for primary care visits, routine hearing and eye exams, and many preventive services, including an annual physical. This plan also provides coverage for inpatient and outpatient services, with varying copays depending on the service, as well as coverage for dental, vision, and hearing services. The plan includes coverage for emergency services and ambulance, with copays for specific services. It also covers home health services, skilled nursing facility stays, and cardiac rehabilitation, with specific cost-sharing structures. Additional benefits include a meal benefit, and no copays for many diagnostic and preventative services.
Inpatient Hospital See details
Inpatient Hospital coverage includes Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you will pay a $310 copay for days 1-6, and no copay for days 7-90; for Inpatient Hospital Psychiatric, you will pay a $335 copay for days 1-6, and no copay for days 7-90. Additional days and upgrades for Inpatient Hospital-Acute and psychiatric stays are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a copay between $0 and $325, Observation Services with a $310 copay, Ambulatory Surgical Center (ASC) Services with no copay, Outpatient Substance Abuse Services with a $35 copay for both individual and group sessions, and Outpatient Blood Services with no copay. Prior authorization is required for all services.
Partial Hospitalization See details
Partial Hospitalization is covered by the Aetna Medicare Premier (PPO) plan, with an $80 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Aetna Medicare Premier (PPO) plan. Ground and Air Ambulance Services have a $300 copay, but there is no 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 Premier (PPO) plan. Emergency Services have a $110 copay, and Urgently Needed Services have a $45 copay, both with no coinsurance. Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $110 copay, and Worldwide Emergency Transportation has a $300 copay, all with no coinsurance.
Primary Care See details
The Aetna Medicare Premier (PPO) plan covers primary care physician services with no copay, chiropractic services with a $15 copay, occupational therapy services with a $35 copay, and physician specialist services with a copay between $0 and $35. The plan also covers mental health specialty services, psychiatric services, and opioid treatment program services, with a $35 copay for individual and group sessions. Physical therapy and speech-language pathology services have a $35 copay, while additional telehealth benefits have a 20% coinsurance and a copay between $0 and $45. However, routine chiropractic care and podiatry services are not covered.
Preventive Services See details
The Aetna Medicare Premier (PPO) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services, including health education, wigs for hair loss, nutritional/dietary benefits, additional sessions of smoking cessation counseling, fitness benefits, remote access technologies, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following welcome visit, are covered with no copay. Kidney disease education services are covered with 20% coinsurance. In-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, enhanced disease management, telemonitoring services, home and bathroom safety devices and modifications, counseling services, and weight management programs are not covered.
Hearing Services See details
The Aetna Medicare Premier (PPO) plan covers hearing exams with a $35 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids (all types) are covered with a maximum copay of $1700, but prescription hearing aids - inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams and eyewear. Eye exams have a copay of $0-$35, and include routine eye exams with no copay, and other eye exam services with no copay. Eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades, have no copay, and a combined maximum benefit of $190 per year.
Dental Services See details
Dental services include coverage for Medicare dental services with a $35 copay, and other dental services with a $1,250 maximum benefit per year. The plan also covers oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery with no copay. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered under the Aetna Medicare Premier (PPO) plan. For Medicare Part B Insulin Drugs, the plan has a $35 copay. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, the coinsurance ranges from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered by the Aetna Medicare Premier (PPO) plan, and require prior authorization. The coinsurance for these services is between 20% and 20%.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a coinsurance between 0% and 20%, while Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
The Aetna Medicare Premier (PPO) plan covers diagnostic and radiological services, including all diagnostic services and radiological services. Diagnostic Procedures/Tests have a copay between $0 and $35, while Lab Services have no copay. Diagnostic Radiological Services have a copay up to $250, and Outpatient X-Ray Services have a copay of $35. Therapeutic Radiological Services have a coinsurance of 20%.
Home Health Services See details
Home Health Services are covered by the Aetna Medicare Premier (PPO) plan with no copay and no coinsurance, though additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the Aetna Medicare Premier (PPO) plan. However, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Aetna Medicare Premier (PPO), with a $0 copay for days 1-20 and a $214 copay per day for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Aetna Medicare Premier (PPO) plan covers Other Services, but acupuncture, over-the-counter items, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered. The plan offers a Meal Benefit with no copay. Other services like annual wellness exams and screening mammography, and gFOBT and FIT have no copay.
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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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