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Aetna Medicare Enhanced (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare Enhanced (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Aetna Medicare Enhanced (PPO) in 2026, please refer to our full plan details page.
Aetna Medicare Enhanced (PPO) is a PPO plan offered by CVS Health Corporation available for enrollment in 2025 to people living in Westchester, Rockland, Bronx Counties. This plan received an overall rating of 4.5 out of 5 stars in 2026.
It's important to know that Aetna Medicare Enhanced (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 Enhanced (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 Enhanced (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $91.00. 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 $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 Enhanced (PPO) plan features an annual drug deductible of $615. Under this plan, you will pay no copay for Tier 1 (Preferred Generic) and Tier 2 (Generic) medications when using preferred pharmacies or preferred mail order services. If you choose standard pharmacies or standard mail order, Tier 1 copays range from $2 to $6, while Tier 2 copays range from $12 to $36 depending on the supply duration. For higher-tier medications, the plan transitions to coinsurance instead of flat copays. Tier 3 (Preferred Brand) drugs require a 24% coinsurance, while Tier 4 (Non-Preferred) and Tier 5 (Specialty) drugs require a 25% coinsurance across all pharmacy and mail-order options. Additionally, Tier 5 specialty drugs are limited to a one-month supply.
Additional Benefits
The Aetna Medicare Enhanced (PPO) plan offers robust healthcare coverage with no copays or coinsurance for primary care doctor visits, home health services, and most preventive care. Specialist visits, diagnostic tests, and vision exams are highly affordable, featuring low copays ranging from $0 to $45. For hospital care and emergencies, members pay predictable copays, including $115 for emergency room visits and a $399 daily copay for the first six days of an acute inpatient hospital stay. This plan also features essential extras like routine dental, vision, and hearing benefits, which include no copays for preventive dental cleanings, annual eye exams, and routine hearing tests. Additionally, there is no copay for the first 20 days in a skilled nursing facility, and most covered services carry no coinsurance to help keep your out-of-pocket costs low.
Inpatient Hospital See details
Aetna Medicare Enhanced (PPO) covers inpatient hospital services with no coinsurance, requiring a $399 daily copay for days 1 through 6 of acute stays (no copay thereafter) and a $346 daily copay for days 1 through 6 of psychiatric stays (no copay for days 7 through 90). The benefit is partially covered, as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services are covered by Aetna Medicare Enhanced (PPO) with no coinsurance, including no copay for ambulatory surgical center and outpatient blood services. Outpatient hospital services require a copay of $0 to $399, observation services carry a $399 copay per stay, and outpatient substance abuse sessions have a $45 copay.
Partial Hospitalization See details
Aetna Medicare Enhanced (PPO) covers partial hospitalization services with a copay of either $105.00 or $110.00 and no coinsurance. Prior authorization is required to receive this covered benefit.
Ambulance and Transportation Services See details
Aetna Medicare Enhanced (PPO) covers ground and air ambulance services with a $285 copay and no coinsurance, with prior authorization required. For transportation, some services are covered but trips to plan-approved or any health-related locations are not covered.
Emergency Services See details
Aetna Medicare Enhanced (PPO) covers emergency services with a $115 copay, which is waived if admitted to the hospital within 24 hours, and urgently needed services with a $40 copay, both with no coinsurance. Worldwide emergency and urgent care are covered with a $115 copay, and worldwide emergency transportation is covered with a $285 copay, all featuring no coinsurance up to a $250,000 maximum plan benefit limit.
Primary Care See details
Aetna Medicare Enhanced (PPO) provides primary care physician services with no copay and no coinsurance, and specialist visits with a $0 to $45 copay and no coinsurance. Physical, occupational, speech, psychiatric, and mental health therapies require copays of $35 to $45 with no coinsurance, while telehealth services carry a $0 to $45 copay and 20% coinsurance. Podiatry is not covered, and while some chiropractic services are covered, routine and other chiropractic services are not.
Preventive Services See details
Preventive services are partially covered by Aetna Medicare Enhanced (PPO), with most services like annual physicals and fitness benefits requiring no copay and no coinsurance. Kidney disease education is covered with no copay and a 20% coinsurance, but several sub-services—including in-home safety assessments, personal emergency response systems, medical nutrition therapy, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, disease management, telemonitoring, home safety devices, and counseling—are not covered.
Hearing Services See details
Hearing services are partially covered by Aetna Medicare Enhanced (PPO) with no deductibles, offering annual routine exams and fitting evaluations with no copay and no coinsurance. Medicare-covered exams require a $45 copay and no coinsurance, and prescription hearing aids are covered up to two times per year with no coinsurance and copays ranging from $0 to $1,700, though OTC, inner ear, outer ear, and over the ear models are not covered.
Vision Services See details
Vision services are covered by Aetna Medicare Enhanced (PPO) with no deductibles and no coinsurance, featuring a $0 to $45 copay for eye exams and no copay for eyewear. Routine eye exams are limited to one per year with a $50 annual maximum benefit, and eyewear services have a combined annual maximum benefit of $100.
Dental Services See details
Dental services are partially covered by Aetna Medicare Enhanced (PPO), which offers preventive care like oral exams, cleanings, and X-rays with no copay and no coinsurance, and Medicare-covered dental services for a $45 copay and no coinsurance. Major services including restorative, endodontics, periodontics, prosthodontics, implants, orthodontics, fluoride, and oral surgery are not covered.
Home Infusion bundled Services See details
Aetna Medicare Enhanced (PPO) covers home infusion bundled services with no copay, though prior authorization and step therapy are required. Under this benefit, Medicare Part B insulin drugs have a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs carry no copay and a 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by Aetna Medicare Enhanced (PPO) with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
Medical equipment is covered by Aetna Medicare Enhanced (PPO) with no copays and coinsurance ranging from no coinsurance up to 20% depending on the item. Covered benefits include durable medical equipment, prosthetics, and diabetic supplies, all of which require prior authorization.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under the Aetna Medicare Enhanced (PPO) with prior authorization required. Diagnostic services feature no coinsurance, with no copay for lab tests and a copay ranging from no copay to $45 for diagnostic procedures, while radiological services require a $45 copay for X-rays, starting at no copay for diagnostic radiology, and a minimum 20% coinsurance for therapeutic radiology.
Home Health Services See details
Home Health Services are covered under the Aetna Medicare Enhanced (PPO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Aetna Medicare Enhanced (PPO) does not cover Cardiac Rehabilitation Services in practice, as all sub-services—including cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation—are not covered. While there is no coinsurance, these individual services require copayments ranging from $15 to $20.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Aetna Medicare Enhanced (PPO) with no coinsurance, featuring no copay for days 1 through 20 and a $185 daily copay for days 21 through 100. Prior authorization is required and a prior three-day hospital stay is not needed, though additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Aetna Medicare Enhanced (PPO) covers select other services with no copay and no coinsurance, including a meal benefit for chronic illness, annual wellness exams, screening mammographies, and additional gFOBT and FIT screenings. However, acupuncture and over-the-counter (OTC) items are not covered under this plan.
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