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Aetna Medicare Essential (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare Essential (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Aetna Medicare Essential (PPO) in 2025, please refer to our full plan details page.
Aetna Medicare Essential (PPO) is a PPO plan offered by CVS Health Corporation available for enrollment in 2025 to people living in Atlanta GA and Southeast AL. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Aetna Medicare Essential (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 Essential (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 Essential (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:
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Drug Coverage
The Aetna Medicare Essential (PPO) plan has a $590 deductible for prescription drugs. Once you meet your deductible, you'll 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, while standard generic drugs have 24% coinsurance. In the initial coverage phase, the plan will pay up to $2000 in total drug costs. After this, you enter the catastrophic coverage phase, where you pay nothing for covered drugs. If you qualify for the low-income subsidy, you will pay $0.00 for Part D drugs.
Additional Benefits
The Aetna Medicare Essential (PPO) plan offers comprehensive coverage, including inpatient and outpatient hospital services, with varying copays for different services. Emergency and urgent care services have copays, while primary care visits have no copay. Preventive services are covered with no copay. This plan includes coverage for hearing, vision, and dental services, with copays and annual maximum benefits for these services. It also covers ambulance, home health, and medical equipment with copays or coinsurance. Other covered services include home infusion, dialysis, and skilled nursing facility stays.
Inpatient Hospital See details
Inpatient Hospital services, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered. For Inpatient Hospital-Acute, there is a $298 copay for days 1-7, and no copay for days 8-90. For Inpatient Hospital Psychiatric, there is a $407 copay for days 1-5, and no copay for days 6-90. Additional days for Inpatient Hospital-Acute are covered with no copay. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute, as well as 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 $298, observation services with a $298 copay, ambulatory surgical center services with no copay, outpatient substance abuse services with a $30 copay for both individual and group sessions, and outpatient blood services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Aetna Medicare Essential (PPO) plan, but requires prior authorization. You will have an $80 copay for this service.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Aetna Medicare Essential (PPO) plan. Ground ambulance services have a $285 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 under the Aetna Medicare Essential (PPO) plan. Emergency Services have a $110 copay, Urgently Needed Services have a $45 copay, Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $110 copay, and Worldwide Emergency Transportation has a $285 copay; all services have no coinsurance.
Primary Care See details
The Aetna Medicare Essential (PPO) plan covers primary care physician services with no copay, chiropractic services with a $15 copay, and occupational therapy services with a $30 copay. Physician specialist services and other health care professionals have a copay between $0 and $40, physical therapy and speech-language pathology services have a $30 copay, and additional telehealth benefits have a 20% coinsurance and a copay between $0 and $45. Mental health specialty services, psychiatric services, and opioid treatment program services are covered with a $30 copay. Podiatry services are not covered.
Preventive Services See details
The Aetna Medicare Essential (PPO) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services, like Health Education, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, EKG following Welcome Visit, and Wigs for Hair Loss Related to Chemotherapy, are covered with no copay. Kidney Disease Education Services are covered with 20% coinsurance.
Hearing Services See details
Hearing services include coverage for hearing exams with a $40 copay, routine hearing exams with no copay for 1 visit per year, fitting/evaluation for hearing aids with no copay for 1 visit per year, and prescription hearing aids with a maximum benefit of $500 per year. 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
The Aetna Medicare Essential (PPO) plan covers vision services, including eye exams with a copay of $0-$40 and eyewear with a $0 copay, and a combined maximum benefit of $310 per year for eyewear. Routine eye exams are covered with no copay for one visit every year, and other eye exam services are covered with no copay.
Dental Services See details
Dental services are covered, with a $40 copay for Medicare dental services, and a $1,200 maximum plan benefit per year. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatments, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are covered with no copay. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Aetna Medicare Essential (PPO) plan, but prior authorization is required. 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, but require prior authorization. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered by the Aetna Medicare Essential (PPO) plan, including Durable Medical Equipment with 20% coinsurance, Prosthetics/Medical Supplies with 20% coinsurance, and Diabetic Equipment, with Diabetic Supplies having 0-20% coinsurance and Diabetic Therapeutic Shoes/Inserts having no copay. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Aetna Medicare Essential (PPO) plan. Diagnostic Procedures/Tests have a copay between $0 and $95, and Lab Services have no copay. Diagnostic Radiological Services have a copay up to $300, Therapeutic Radiological Services have a coinsurance of at least 20%, and Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Aetna Medicare Essential (PPO) plan with no copay and no coinsurance; however, additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Aetna Medicare Essential (PPO) plan. The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Aetna Medicare Essential (PPO) with prior authorization required. There is no copay for days 1-20, and a $214 copay for days 21-100. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Aetna Medicare Essential (PPO) plan covers over-the-counter items with a $0 copay, and a maximum benefit coverage amount of $30 every three months. Other services such as acupuncture, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and more are not covered.
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