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Aetna Medicare Elite (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare Elite (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Aetna Medicare Elite (PPO) in 2026, please refer to our full plan details page.
Aetna Medicare Elite (PPO) is a PPO plan offered by CVS Health Corporation available for enrollment in 2025 to people living in Select Atlanta Metro Counties. This plan received an overall rating of 4.5 out of 5 stars in 2026.
It's important to know that Aetna Medicare Elite (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 Elite (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 Elite (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 has a $350.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
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 combined Maximum Out-Of-Pocket cost of $13900.00 (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 $13900.00 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 Elite (PPO) prescription drug plan features an annual drug deductible of $615. For generic medications, you can benefit from no copay on both Tier 1 preferred generics and Tier 2 generics when using preferred pharmacies or preferred mail order services. If you choose standard pharmacies or standard mail order, Tier 1 copays start at $2 and Tier 2 copays start at $12 for a one-month supply. For higher-tier medications, costs transition to coinsurance across all pharmacy and mail order options. Tier 3 preferred brand drugs require a 24% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs both carry a 25% coinsurance. This structure helps you plan your prescription drug expenses based on the specific tiers of your medications.
Additional Benefits
The Aetna Medicare Elite (PPO) plan offers robust core medical coverage, featuring no copay and no coinsurance for primary care visits and routine preventive care. Inpatient hospital stays require daily copays for the first several days before transitioning to no copay, while emergency room visits carry a flat $115 copay that is waived if you are admitted. Outpatient and home health services are also widely covered, often requiring no copay or coinsurance depending on the specific service. For ancillary care, members enjoy preventive dental, routine vision, and routine hearing exams with no copay or coinsurance, alongside annual allowances for eyewear and hearing aids. While specialized treatments like dialysis and durable medical equipment generally require a 20% coinsurance, the plan adds value with extra perks like a quarterly over-the-counter allowance. Please note that several services, such as inpatient stays and diagnostic imaging, require prior authorization.
Inpatient Hospital See details
Inpatient hospital services are partially covered by Aetna Medicare Elite (PPO) with no coinsurance, though prior authorization is required. Acute stays require a $388 daily copay for days 1 through 7 and no copay for additional days, while psychiatric stays require a $407 daily copay for days 1 through 5 and no copay for days 6 through 90. Hospital upgrades, additional psychiatric days, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient services are covered by Aetna Medicare Elite (PPO) with no coinsurance, featuring no copay for ambulatory surgical center and blood services. Covered outpatient hospital services require a copay of $0 to $450, observation services require a $388 copay per stay, and outpatient substance abuse sessions require a $35 copay.
Partial Hospitalization See details
Aetna Medicare Elite (PPO) covers partial hospitalization services with a copay of $105.00 or $110.00 and no coinsurance. Prior authorization is required to access this benefit.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by Aetna Medicare Elite (PPO), with ground ambulance services requiring a $295 copay and coinsurance, and air ambulance services requiring a 20% coinsurance and copay, both subject to prior authorization. Although some transportation services are covered, transportation to plan-approved or any health-related locations is not covered in practice.
Emergency Services See details
Aetna Medicare Elite (PPO) covers emergency services with a $115 copay and no coinsurance, with the copay waived if admitted to the hospital within 24 hours. Urgently needed services have a $40 copay and no coinsurance, while worldwide emergency services are covered up to a $250,000 limit with no coinsurance and copays of $115 for emergency or urgent care and $295 for emergency transportation.
Primary Care See details
Aetna Medicare Elite (PPO) offers primary care physician services with no copay and no coinsurance, while specialist visits range from no copay to a $55 copay with no coinsurance. Physical, occupational, mental health, and psychiatric therapies require copays between $35 and $50 with no coinsurance, and telehealth services have a 20% coinsurance and up to a $55 copay, though chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive services are partially covered by Aetna Medicare Elite (PPO), with most covered options like annual physicals and glaucoma screenings requiring no copay and no coinsurance. While kidney disease education is covered with no copay and a 20% coinsurance, several supplemental benefits—including medical nutrition therapy, weight management programs, and personal emergency response systems—are not covered.
Hearing Services See details
Aetna Medicare Elite (PPO) covers Medicare-covered hearing exams with a $55 copay and no coinsurance, while routine exams and fitting evaluations have no copay and no coinsurance. Prescription hearing aids are partially covered with no copay and no coinsurance up to a $500 maximum per ear annually, but OTC hearing aids and prescription inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
Vision services are covered by Aetna Medicare Elite (PPO) with no deductibles and no coinsurance, featuring a $0 to $55 copay for eye exams and a $50 annual maximum limit. Eyewear, including contacts and eyeglasses, is covered with no copay and no coinsurance up to a combined annual maximum benefit of $200.
Dental Services See details
Aetna Medicare Elite (PPO) covers preventive dental services like exams and cleanings with no copay or coinsurance, while Medicare-covered dental requires a $55 copay and no coinsurance. Comprehensive dental services are partially covered with no copay and 20% to 50% coinsurance up to a $2,000 annual limit, though fluoride, implants, maxillofacial prosthetics, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Aetna Medicare Elite (PPO) with no copay, though prior authorization is required. Related Medicare Part B chemotherapy and other drugs carry a coinsurance of 0% to 20%, while Medicare Part B insulin is covered with a $35 copay and no coinsurance.
Dialysis Services See details
Aetna Medicare Elite (PPO) covers dialysis services with no copay and a 20% coinsurance. Prior authorization is required to receive these covered services.
Medical Equipment See details
Aetna Medicare Elite (PPO) covers durable medical equipment, prosthetics, and medical supplies with no copay and 20% coinsurance. Diabetic supplies are covered with no copay and coinsurance ranging from no coinsurance to 20%, while diabetic therapeutic shoes and inserts require a $10 copay and no coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Aetna Medicare Elite (PPO) with prior authorization, offering diagnostic services with no coinsurance, no copay for lab tests, and a $0 to $120 copay for other diagnostic procedures. Covered radiological services include outpatient x-rays with no copay and applicable coinsurance, diagnostic radiology with copays starting at $0, and therapeutic radiology with a minimum 20% coinsurance and applicable copays.
Home Health Services See details
Home Health Services are covered by Aetna Medicare Elite (PPO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by Aetna Medicare Elite (PPO) with no coinsurance, and some services are covered. However, cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for peripheral artery disease (PAD) services are not covered in practice and carry copays ranging from $20 to $40.
Skilled Nursing Facility (SNF) See details
Aetna Medicare Elite (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required and a prior three-day hospital stay is not needed, but additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Other Services under the Aetna Medicare Elite (PPO) are partially covered with no copay and no coinsurance, including chronic illness meal benefits, select wellness screenings, and a $15 quarterly over-the-counter allowance. Acupuncture is not covered under this benefit.
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