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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 SNJ Counties: ATL, BUR, CAM, CPM, CUM, GLO, ON. 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 $54.00. 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 $500.00 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 features an annual drug deductible of $500. Under this plan, you will enjoy no copay for Tier 1 (Preferred Generic) and Tier 2 (Generic) prescription drugs when using a preferred pharmacy or preferred mail-order service. If you choose a standard pharmacy or standard mail-order option, Tier 1 drugs carry a copay starting at $2.00, while Tier 2 drugs start at a $12.00 copay for a one-month supply. For brand-name and specialty medications, your costs are based on coinsurance across all pharmacy types. Tier 3 (Preferred Brand) drugs require a 22% coinsurance, while Tier 4 (Non-Preferred) drugs have a 25% coinsurance for one-, two-, or three-month fills. Specialty Tier 5 medications are covered with a 27% coinsurance for a one-month supply.
Additional Benefits
The Aetna Medicare Elite (PPO) plan offers robust coverage for everyday health needs, featuring no copays or coinsurance for primary care visits, annual physicals, and preventive dental cleanings. Routine vision and hearing exams also have no copay, and the plan includes a $150 annual eyewear allowance alongside hearing aid coverage with copays from $0 to $1,700. Specialist visits are highly affordable, requiring a low copay of $0 to $35 with no coinsurance. For major medical services, inpatient hospital stays require a $900 copay per stay with no coinsurance, while emergency room visits carry a $115 copay. Outpatient surgery and home health services are available with no copays, whereas dialysis and certain diagnostic services require a 20% coinsurance. Durable medical equipment and diabetic supplies are also covered with no copay and coinsurance up to 18% or 20%.
Inpatient Hospital See details
Aetna Medicare Elite (PPO) partially covers inpatient hospital services with no coinsurance, though prior authorization is required. Medicare-covered acute stays require a $900 copay per stay with no copay for unlimited additional days, while psychiatric stays require a $346 daily copay for days 1 through 6 and no copay for days 7 through 90. Non-Medicare-covered stays, hospital upgrades, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services under the Aetna Medicare Elite (PPO) are covered with no coinsurance, including ambulatory surgical center and outpatient blood services which both feature no copays. Outpatient hospital services require a copay of $0 to $350, observation services carry a $350 copay per stay, and outpatient substance abuse sessions have a $35 copay.
Partial Hospitalization See details
Aetna Medicare Elite (PPO) covers partial hospitalization services with no coinsurance, requiring a copay of either $60.00 or $110.00 depending on the service. Prior authorization is required for these covered benefits.
Ambulance and Transportation Services See details
Aetna Medicare Elite (PPO) covers ground and air ambulance services with a $280 copay and no coinsurance, though prior authorization is required. Routine transportation services to health-related locations are not covered under this plan.
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 require a $40 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered up to a $250,000 maximum with copays ranging from $115 to $280 and no coinsurance.
Primary Care See details
Primary care benefits under the Aetna Medicare Elite (PPO) include 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 mental health therapies require copays of $20 to $35 with no coinsurance, while podiatry is not covered, and chiropractic care has some services covered but routine and other chiropractic services are not.
Preventive Services See details
Preventive services are partially covered by Aetna Medicare Elite (PPO), featuring no copay and no coinsurance for annual physical exams, health education, and screenings, while kidney disease education requires a 20% coinsurance and no copay. Several supplemental services are not covered, including in-home safety assessments, personal emergency response systems, medical nutrition therapy, and weight management programs.
Hearing Services See details
Aetna Medicare Elite (PPO) partially covers hearing services, offering annual routine exams and fitting evaluations with no copay and no coinsurance, while Medicare-covered exams require a $35 copay and no coinsurance. Prescription hearing aids are covered with no coinsurance and copays ranging from $0 to $1,700 for up to two aids per year, though OTC, 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 or coinsurance, featuring no copay for routine eye exams and a copay of $0 to $35 for Medicare-covered exams. Eyewear, including contacts, frames, and lenses, is also covered with no copay and no coinsurance up to a combined maximum benefit of $150 per year.
Dental Services See details
Dental services are partially covered by Aetna Medicare Elite (PPO), with Medicare-covered dental requiring a $35.00 copay and no coinsurance, while covered preventive services like oral exams, cleanings, and X-rays have no copay and no coinsurance. However, several services are not covered under this plan, including fluoride treatment, restorative care, endodontics, periodontics, prosthodontics, implants, and oral surgery.
Home Infusion bundled Services See details
Aetna Medicare Elite (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Under this benefit, Medicare Part B insulin drugs have a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs have no copay and a coinsurance ranging from 0% to 20%.
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 diabetic supplies with no copay, though prior authorization is required. Coinsurance costs range from no coinsurance up to 18% for durable medical equipment and prosthetics, and up to 20% for diabetic supplies and therapeutic shoes.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Aetna Medicare Elite (PPO), with lab services and diagnostic radiology offered at no copay and no coinsurance. Diagnostic tests and procedures have a copay of up to $35 with no coinsurance, outpatient X-rays require a $35 copay plus coinsurance, and therapeutic radiology carries a minimum 20% coinsurance.
Home Health Services See details
Home health services are covered under the Aetna Medicare Elite (PPO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are partially covered by Aetna Medicare Elite (PPO) with no copay and no coinsurance. However, standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) services are not covered by the plan.
Skilled Nursing Facility (SNF) See details
Aetna Medicare Elite (PPO) covers skilled nursing facility (SNF) services with no coinsurance and no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100. Prior authorization is required, and while a prior three-day hospital stay is not necessary, additional days beyond the standard 100 days are not covered.
Other Services See details
Aetna Medicare Elite (PPO) other services are partially covered, offering a meal benefit, 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 benefit.
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