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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.
This summary reflects 2026 plan information. Where this plan continues in 2027, the full plan details page links to its 2027 benefits and costs.
Aetna Medicare Elite (PPO) is a PPO plan offered by Aetna Life Insurance Company available for the 2026 plan year to people living in Metro: LI, BX, BK, Queens, Westchester/Rockland. 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 that applies only to drugs in certain tiers. You pay this amount toward covered prescriptions in those tiers before the plan's cost sharing begins; drugs in the other tiers are not subject to the deductible. See the full plan details page for the tier table.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $9250.00 for in-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $9250.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
This plan has a Maximum Out-Of-Pocket cost of $13900.00 (in-network and out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $13900.00 for covered services, the plan will pay 100% of 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 Elite (PPO) plan features an annual drug deductible of $615. For Tier 1 preferred generic and Tier 2 generic medications, there is no copay when filled through a preferred pharmacy or preferred mail order. If you choose a standard pharmacy or standard mail order, Tier 1 drugs carry a copay starting at $2, while Tier 2 drugs start at a $12 copay for a one-month supply. For higher-tier medications, costs transition to coinsurance instead of flat copays. Tier 3 preferred brand drugs require a 24% coinsurance across all pharmacy and mail-order options. Tier 4 non-preferred drugs and Tier 5 specialty drugs both carry a 25% coinsurance, with Tier 5 coverage limited to a one-month supply.
Additional Benefits
The Aetna Medicare Elite (PPO) plan offers robust medical coverage with predictable costs, featuring a low $5 copay for primary care visits and no copay to a $45 copay for specialists, with no coinsurance for either. Emergency room visits require a $115 copay, which is waived if you are admitted, while urgent care visits carry a $40 copay. For hospital stays, inpatient acute services require a $399 daily copay for the first six days and no copay thereafter, while outpatient hospital services range from no copay to a $399 copay with no coinsurance. Routine wellness benefits are highly accessible, with no copay and no coinsurance for annual physicals, fitness programs, preventive dental cleanings, and routine vision and hearing exams. While home health services also feature no copay, other specialized needs like durable medical equipment and dialysis require up to a 20% coinsurance. Skilled nursing facility stays are covered with no coinsurance, requiring no copay for the first 20 days and a $218 daily copay for days 21 through 100.
Inpatient Hospital See details
Aetna Medicare Elite (PPO) covers inpatient hospital services with no coinsurance, requiring a $399 daily copay for days 1 through 6 of acute stays and a $346 daily copay for days 1 through 6 of psychiatric stays, with no copay for subsequent covered days. Prior authorization is required, and this benefit is partially covered as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services covered by Aetna Medicare Elite (PPO) feature no coinsurance across all categories, with no copay required for ambulatory surgical center and outpatient blood services. Outpatient hospital services have a copay ranging from no copay to $399, while observation services require a $399 copay per stay and outpatient substance abuse sessions carry a $40 copay.
Partial Hospitalization See details
Partial hospitalization is covered by Aetna Medicare Elite (PPO) 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 emergency ground and air ambulance services with a $285 copay and no coinsurance, though prior authorization is required. While some transportation services are covered, transportation to plan-approved locations and any other health-related locations is not covered.
Emergency Services See details
Aetna Medicare Elite (PPO) covers emergency services with a $115 copay (waived if admitted to the hospital within 24 hours) and urgently needed services with a $40 copay, with no coinsurance required for either. Worldwide emergency, urgent, and transportation services are also covered up to a $250,000 lifetime maximum with no coinsurance and copays ranging from $115 to $285.
Primary Care See details
Aetna Medicare Elite (PPO) covers primary care physician services for a $5 copay and no coinsurance, and specialist visits for no copay to a $45 copay with no coinsurance. Physical and occupational therapy services require a $35 copay and no coinsurance, while podiatry and routine chiropractic services are not covered.
Preventive Services See details
Preventive Services under Aetna Medicare Elite (PPO) are partially covered, featuring no copay and no coinsurance for annual physicals, glaucoma screenings, and fitness benefits, while kidney disease education has no copay but a 20% coinsurance. Several supplemental benefits are not covered, including in-home safety assessments, personal emergency response systems, medical nutrition therapy, weight management programs, and alternative therapies.
Hearing Services See details
Hearing services under the Aetna Medicare Elite (PPO) include Medicare-covered exams for a $45 copay and no coinsurance, as well as annual routine exams and fitting evaluations with no copay and no coinsurance. Prescription hearing aids are partially covered with no coinsurance and a copay ranging from $0 to $1,700, but inner ear, outer ear, over the ear, and over-the-counter hearing aids are not covered.
Vision Services See details
Vision services are covered by Aetna Medicare Elite (PPO) with no deductible and no coinsurance, offering eye exams with no copay to a $45 copay up to a $50 annual limit. Eyewear, including contacts and eyeglasses, is also covered with no copay and no coinsurance up to a combined limit of $100 per year.
Dental Services See details
Dental services are partially covered by the Aetna Medicare Elite (PPO), featuring a $45 copay and no coinsurance for Medicare-covered dental services, and no copay and no coinsurance for covered preventive services like oral exams, cleanings, and X-rays. Many other dental services are not covered, including fluoride, restorative care, endodontics, periodontics, prosthodontics, implants, oral surgery, and orthodontics.
Home Infusion bundled Services See details
Aetna Medicare Elite (PPO) covers home infusion bundled services with no copay, though prior authorization and step therapy are required. Covered Medicare Part B chemotherapy and other drugs carry a 0% to 20% coinsurance, while Part B insulin is covered with a $35 copay and no coinsurance.
Dialysis Services See details
Dialysis services are covered by the Aetna Medicare Elite (PPO) plan 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 medical equipment, including durable medical equipment, prosthetics, and diabetic supplies, with no copay and prior authorization required. Depending on the item, coinsurance ranges from no coinsurance up to 20%, with a flat 20% coinsurance specifically applying to prosthetic devices and diabetic therapeutic shoes or inserts.
Diagnostic and Radiological Services See details
Aetna Medicare Elite (PPO) covers diagnostic and radiological services, with prior authorization required for these benefits. Diagnostic tests feature no coinsurance and a copay ranging from $0 to $45, lab services and diagnostic radiology require no copay, and outpatient x-rays have a $45 copay while therapeutic radiology services carry a 20% coinsurance.
Home Health Services See details
Aetna Medicare Elite (PPO) covers Home Health Services 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 while some services are covered, cardiac rehabilitation, intensive cardiac rehabilitation, and SET for PAD services (each with a $20 copay) along with pulmonary rehabilitation services (with a $15 copay) are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Aetna Medicare Elite (PPO) with no coinsurance, requiring prior authorization but no prior three-day hospital stay. There is no copay for days 1 through 20, a $218 daily copay for days 21 through 100, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Aetna Medicare Elite (PPO) partially covers other services, providing a meal benefit for chronic illness, annual wellness exams, screening mammographies, and additional gFOBT and FIT screenings with no copay and no coinsurance. Acupuncture and over-the-counter (OTC) items are not covered under this plan.
Plan Providers
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, Health Care Service Corporation, HealthSpringSM, HealthSun, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
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