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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 Pennsylvania. 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 $183.00. 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 $750.00 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 $11300.00 (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 $11300.00 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. For prescription savings, Tier 1 preferred generics and Tier 2 generics have no copay when filled at preferred pharmacies or through preferred mail order services. If you use standard pharmacies or standard mail order, Tier 1 drugs carry a copay starting at $2, while Tier 2 drugs start at $12 for a one-month supply. For higher-tier medications, costs shift to coinsurance rather than set copays. Tier 3 preferred brand-name drugs require a 24% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs both carry a 25% coinsurance across all pharmacy types. Specialty medications are restricted to a one-month supply, but other tiers offer two- and three-month supply options to fit your ongoing healthcare needs.
Additional Benefits
The Aetna Medicare Enhanced (PPO) plan offers robust coverage for essential medical services, featuring no copays or coinsurance for primary care visits, home health services, and annual routine vision and hearing exams. For specialized care, specialist visits require a low copay of up to $35, while inpatient hospital stays require an $800 copay per stay with no coinsurance. Outpatient hospital services and emergency room visits are also covered with manageable copays and no coinsurance, ensuring predictable costs for major medical needs. This plan also includes valuable supplemental benefits, such as no-copay preventive dental care and up to $1,000 in comprehensive dental coverage with 20% to 50% coinsurance. Additionally, members benefit from a $500 annual allowance for prescription hearing aids and a $30 quarterly over-the-counter allowance with no copays. Most medical equipment, diagnostic services, and Part B drugs are covered with no copays or coinsurance ranging up to 20%, providing well-rounded financial protection.
Inpatient Hospital See details
Aetna Medicare Enhanced (PPO) covers inpatient hospital services with no coinsurance, though prior authorization is required. Acute care requires an $800 copay per stay with no copay for unlimited additional days, while psychiatric care has a $350 daily copay for days 1 to 5 and no copay for days 6 to 90. Upgrades and non-Medicare-covered stays are not covered under this benefit.
Outpatient Services See details
Aetna Medicare Enhanced (PPO) covers outpatient services with no coinsurance, including no copay for ambulatory surgical center and blood services. Outpatient hospital services carry a copay of $0 to $300, while observation services require a $300 copay per stay, and individual or group outpatient substance abuse sessions have a $40 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 for these covered services.
Ambulance and Transportation Services See details
Aetna Medicare Enhanced (PPO) covers ambulance services with prior authorization, requiring a $300 copay and no coinsurance for ground transport, and a 20% coinsurance with no copay for air transport. Some transportation 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 and no coinsurance, with the copay waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $40 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with no coinsurance and copays ranging from $115 to $300, up to a maximum benefit limit of $250,000.
Primary Care See details
Primary care benefits under the Aetna Medicare Enhanced (PPO) are partially covered, featuring primary care physician visits with no copay and no coinsurance, and specialist visits with a $0 to $35 copay and no coinsurance. Physical, occupational, and speech therapies require a $15 copay and no coinsurance, mental health services have a $40 copay and no coinsurance, while podiatry and chiropractic services are not covered.
Preventive Services See details
Aetna Medicare Enhanced (PPO) offers partially covered preventive services, featuring no copay and no coinsurance for annual physicals, glaucoma screenings, diabetes training, and select supplemental benefits like memory fitness. Kidney disease education is covered with a 20% coinsurance and no copay, while several sub-services such as weight management, in-home support, and nutritional benefits are not covered.
Hearing Services See details
Hearing services are partially covered by Aetna Medicare Enhanced (PPO), featuring Medicare-covered exams for a $35 copay and no coinsurance, alongside annual routine exams and fitting evaluations with no copay and no coinsurance. Prescription hearing aids are covered up to $500 annually with no copay and no coinsurance, but OTC hearing aids and inner ear, outer ear, and over-the-ear prescription models are not covered.
Vision Services See details
Vision services covered by the Aetna Medicare Enhanced (PPO) include routine eye exams and eyewear with no copay and no coinsurance, subject to annual maximum benefits of $50 for exams and $150 for eyewear. Medicare-covered eye exams require a copay of $0 to $35 with no coinsurance, and there are no deductibles for any vision services.
Dental Services See details
Dental services are partially covered by Aetna Medicare Enhanced (PPO), featuring a $35 copay and no coinsurance for Medicare-covered dental, no copay and no coinsurance for preventive care, and no copay with 20% to 50% coinsurance for comprehensive care up to a $1,000 annual limit. Fluoride, implants, orthodontics, and maxillofacial prosthetics are not covered under this plan.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by Aetna Medicare Enhanced (PPO) with no copay, though prior authorization is required. Covered Medicare Part B chemotherapy, radiation, and other Part B drugs carry a coinsurance of 0% to 20%, while Part B insulin is covered with a $35 copay and no coinsurance.
Dialysis Services See details
Dialysis services are covered under the Aetna Medicare Enhanced (PPO) plan with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
Medical equipment is covered by Aetna Medicare Enhanced (PPO), with prior authorization required for most items. Covered durable medical equipment, prosthetics, medical supplies, and diabetic therapeutic shoes have no copay, with coinsurance ranging from 0% to 20% depending on the service.
Diagnostic and Radiological Services See details
Aetna Medicare Enhanced (PPO) covers diagnostic and radiological services with prior authorization, offering lab services and diagnostic radiology with no copay or coinsurance. Diagnostic tests carry a $0 to $5 copay with no coinsurance, outpatient X-rays require a $15 copay plus coinsurance, and therapeutic radiological services require a minimum 20% coinsurance.
Home Health Services See details
Aetna Medicare Enhanced (PPO) covers home health services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by Aetna Medicare Enhanced (PPO) with no copay and no coinsurance, though in practice only some services are covered. Specifically, standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) services are not covered.
Skilled Nursing Facility (SNF) See details
Aetna Medicare Enhanced (PPO) covers skilled nursing facility (SNF) services with no coinsurance, offering no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, a three-day prior hospital stay is not required, and additional days beyond the 100-day Medicare limit are not covered.
Other Services See details
Aetna Medicare Enhanced (PPO) partially covers other services with no copay and no coinsurance for over-the-counter items up to $30 every three months, chronic illness meal benefits, annual wellness exams, and additional cancer screenings, while acupuncture is not covered.
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