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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 Capital Region and Hudson Valley Area. 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 $1000.00 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) plan has an annual drug deductible of $615. For Tier 1 preferred generic and Tier 2 generic drugs, there is no copay when filled through a preferred pharmacy or preferred mail order. If you use standard pharmacies or standard mail order services, copays range from $2 to $6 for Tier 1 and $12 to $36 for Tier 2 depending on the supply length. For brand-name and specialty medications, the plan transitions to a coinsurance model. You will pay a 24% coinsurance for Tier 3 preferred brand drugs at any pharmacy or mail order option. Tier 4 non-preferred drugs and Tier 5 specialty drugs both require a 25% coinsurance, with specialty coverage limited to a one-month supply.
Additional Benefits
The Aetna Medicare Elite (PPO) plan offers predictable medical costs with no coinsurance for many core services, including inpatient hospital stays, outpatient care, and doctor visits. Primary care visits require a low $5 copay, while specialist visits range from no copay to a $45 copay. Emergency care is available with a $115 copay, which is waived if you are admitted, and urgent care visits cost $40. Routine preventive care, home health services, and annual vision and hearing exams are available with no copay or coinsurance. The plan also includes dental coverage with no copay up to a $750 annual maximum, along with allowances for eyewear and hearing aids to help keep your out-of-pocket costs low. Medicare-covered durable medical equipment and dialysis services are covered with coinsurance ranging up to 20%.
Inpatient Hospital See details
Aetna Medicare Elite (PPO) covers inpatient hospital services with no coinsurance, though prior authorization is required. For acute stays, there is a $407 daily copay for days 1 to 6 and no copay for subsequent unlimited days, while psychiatric stays cost $346 per day for days 1 to 6 and no copay for days 7 to 90. This benefit is partially covered, as upgrades, additional psychiatric days, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Aetna Medicare Elite (PPO) covers outpatient services with no coinsurance, offering no copays for ambulatory surgical center and blood services. Outpatient hospital services carry a copay of $0 to $407, observation services require a $407 copay per stay, and outpatient substance abuse sessions have a $40 copay, with prior authorization required for select services.
Partial Hospitalization See details
Partial hospitalization services are covered under the Aetna Medicare Elite (PPO) plan with a copay of $105.00 or $110.00 and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
Aetna Medicare Elite (PPO) covers ground and air ambulance services with a $300 copay and no coinsurance, though prior authorization is required. Transportation services to plan-approved or other health-related locations are not covered.
Emergency Services See details
Aetna Medicare Elite (PPO) covers emergency services with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services are covered with a $40 copay and no coinsurance, while worldwide emergency services are covered up to a $250,000 limit with no coinsurance and copays ranging from $115 to $300.
Primary Care See details
Primary care benefits under the Aetna Medicare Elite (PPO) include primary care visits for a $5 copay and specialist visits for a copay ranging from no copay to $45, both with no coinsurance. Physical, occupational, and speech therapies require a $35 copay with no coinsurance, while mental health, psychiatric, and opioid services require a $40 copay and no coinsurance. Chiropractic and podiatry services are not covered, but telehealth is offered with a copay of no copay to $45 and 20% coinsurance.
Preventive Services See details
Preventive services are partially covered by Aetna Medicare Elite (PPO), featuring no copay and no coinsurance for annual exams and screenings, though kidney disease education requires no copay and a 20% coinsurance. Excluded from coverage are 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/dietary benefits, home-based palliative care, in-home support, caregiver support, enhanced disease management, telemonitoring, home safety modifications, and counseling.
Hearing Services See details
Hearing services are covered by the Aetna Medicare Elite (PPO) plan, featuring a $45 copay for Medicare-covered exams and no copay or coinsurance for annual routine exams and fitting evaluations. Prescription hearing aids are partially covered with no coinsurance and copays ranging from $0 to $1,700, though over-the-counter devices and inner ear, outer ear, or over-the-ear prescription models are not covered.
Vision Services See details
Aetna Medicare Elite (PPO) covers vision services with no deductible and no coinsurance, offering routine eye exams and eyewear with no copay. There is a $50 annual maximum benefit for eye exams (with a $0 to $45 copay for Medicare-covered exams) and a $100 combined annual maximum for eyewear.
Dental Services See details
Dental services are partially covered by Aetna Medicare Elite (PPO), offering most preventive and comprehensive services with no copay and no coinsurance up to a $750 annual maximum for both in-network and out-of-network care. Medicare-covered dental services require a $45 copay and no coinsurance, but maxillofacial prosthetics, implant services, 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 and no coinsurance, though prior authorization is required. Medicare Part B insulin drugs require a $35 copay and no coinsurance, while chemotherapy and other Part B drugs have no copay and a 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by Aetna Medicare Elite (PPO) with no copay and a 20% coinsurance. Prior authorization is required to receive these covered services.
Medical Equipment See details
Medical equipment is covered under Aetna Medicare Elite (PPO) with no copay and coinsurance ranging from no coinsurance to 20% for durable medical equipment, prosthetics, and diabetic supplies. Prior authorization is required for these benefits, and diabetic supplies are limited to specified manufacturers.
Diagnostic and Radiological Services See details
Aetna Medicare Elite (PPO) covers diagnostic and radiological services with prior authorization, offering lab services and diagnostic radiology with no copays. Outpatient diagnostic tests have a copay of $0 to $45 with no coinsurance, while outpatient X-rays require a $45 copay and therapeutic radiological services carry a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered by the Aetna Medicare Elite (PPO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Aetna Medicare Elite (PPO) covers cardiac rehabilitation services with no coinsurance, but some services are covered while cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered and require copays ranging from $15 to $20.
Skilled Nursing Facility (SNF) See details
Aetna Medicare Elite (PPO) partially covers Skilled Nursing Facility (SNF) services with no coinsurance, as additional days beyond the Medicare-covered 100 days are not covered. There is no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, with prior authorization required but no prior three-day hospital stay needed.
Other Services See details
Other Services are partially covered under the Aetna Medicare Elite (PPO) plan, with no coverage provided for acupuncture or over-the-counter (OTC) items. Covered services, including chronic illness meal benefits, annual wellness exams, screening mammographies, and additional gFOBT and FIT screenings, are available with no copay and no coinsurance.
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