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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 North Carolina. 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 $21.00. 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 $7750.00 (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 $7750.00 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 generic medications, members pay no copay on Tier 1 (Preferred Generic) and Tier 2 (Generic) drugs when using preferred pharmacies or preferred mail-order services. If standard pharmacies or mail-order options are used, Tier 1 copays start at $2 and Tier 2 copays start at $12 for a one-month supply. For higher-tier medications, the plan utilizes coinsurance instead of flat copays. Tier 3 (Preferred Brand) drugs require a 24% coinsurance, while Tier 4 (Non-Preferred) and Tier 5 (Specialty) drugs carry a 25% coinsurance. These coinsurance rates remain consistent across preferred, standard, and mail-order pharmacy options.
Additional Benefits
The Aetna Medicare Enhanced (PPO) plan provides strong medical coverage with predictable out-of-pocket expenses, including no copay for primary care visits and copays up to $35 for specialists. Emergency room visits carry a $130 copay, which is waived if you are admitted, while urgently needed care has a $50 copay. For inpatient hospital stays, members pay a daily copay for the first eight days, with no copay required for days 9 through 90. In addition to medical care, the plan covers routine dental, vision, and hearing services with no copay for preventive care. Vision benefits feature no copay for eyewear up to a $100 annual maximum, and hearing coverage includes up to two prescription hearing aids per year with no copay up to $1,250 per ear. Members also benefit from home health services and an over-the-counter item allowance with no copays.
Inpatient Hospital See details
Aetna Medicare Enhanced (PPO) partially covers inpatient hospital services with no coinsurance, though prior authorization is required. Acute stays require a $382 daily copay for days 1-8 and no copay for days 9-90 with unlimited additional days, while psychiatric stays require a $292 daily copay for days 1-8 and no copay for days 9-90; upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Aetna Medicare Enhanced (PPO) covers outpatient services with no coinsurance, including outpatient blood services and ambulatory surgical center services with no copays. Outpatient hospital services carry a copay of $0 to $382, observation services require a $382 copay per stay, and outpatient substance abuse sessions have a $40 copay.
Partial Hospitalization See details
Partial hospitalization is covered under the Aetna Medicare Enhanced (PPO) plan with a copay of $140.00 or $145.00 and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by Aetna Medicare Enhanced (PPO), with ground ambulance services requiring a $275 copay and no coinsurance, and air ambulance services requiring a 20% coinsurance and no copay. Prior authorization is required for all ambulance services, and while some transportation services are covered, trips to plan-approved or any other health-related locations are not covered.
Emergency Services See details
Aetna Medicare Enhanced (PPO) covers emergency services with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services have a $50 copay and no coinsurance, while worldwide emergency care is covered up to $250,000 with no coinsurance and copays ranging from $130 to $275.
Primary Care See details
Aetna Medicare Enhanced (PPO) covers primary care physician services with no copay and no coinsurance, and specialist visits with a $0 to $35 copay and no coinsurance. Therapy, mental health, and psychiatric services require copays of $35 to $40 with no coinsurance, while telehealth has a $0 to $50 copay and 20% coinsurance. Chiropractic care is only partially covered as routine and other chiropractic services are not covered, and podiatry is not covered.
Preventive Services See details
Preventive Services are partially covered by Aetna Medicare Enhanced (PPO) with no copay and no coinsurance for most services like annual physicals and health education, while kidney disease education has no copay but requires a 20% coinsurance. Services not covered under this benefit include 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 devices, and counseling.
Hearing Services See details
Hearing services are partially covered by the Aetna Medicare Enhanced (PPO), featuring Medicare-covered exams for a $35 copay and no coinsurance, plus annual routine exams and fitting evaluations with no copay and no coinsurance. Up to two prescription hearing aids are covered annually with no copay and no coinsurance up to a $1,250 limit per ear; however, OTC hearing aids as well as inner ear, outer ear, and over-the-ear prescription hearing aids 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 $35 copay for eye exams and no copay for eyewear. This includes a $50 annual maximum benefit for eye exams, which covers one routine exam per year, and a $100 combined annual maximum benefit for eyewear like eyeglasses and contact lenses.
Dental Services See details
Dental services are partially covered under the Aetna Medicare Enhanced (PPO) with a $35 copay and no coinsurance for Medicare-covered dental, and no copay or coinsurance for preventive exams, cleanings, and x-rays. Comprehensive services are covered with no copay and 20% to 50% coinsurance up to a $1,000 annual maximum, though fluoride, implants, orthodontics, maxillofacial prosthetics, other diagnostic, and other preventive dental services are not covered.
Home Infusion bundled Services See details
Aetna Medicare Enhanced (PPO) covers home infusion bundled services with no copay and no coinsurance, although prior authorization is required. Under this benefit, Medicare Part B insulin has a $35 copay and no coinsurance, while chemotherapy and other Part B drugs have no copay and a coinsurance ranging from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered by Aetna Medicare Enhanced (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 by Aetna Medicare Enhanced (PPO) with no copays and coinsurance ranging from 0% to 20% for durable medical equipment, prosthetics, medical supplies, and diabetic services. Prior authorization is required for several of these benefits, and diabetic supplies are limited to specified manufacturers.
Diagnostic and Radiological Services See details
Aetna Medicare Enhanced (PPO) covers diagnostic and radiological services, with prior authorization required for both. Diagnostic services have no coinsurance, offering no copay for lab services and a $0 to $200 copay for procedures. Radiological services feature no copay for outpatient X-rays (coinsurance applies), copays starting at $0 for diagnostic radiology, and a copay plus a minimum 20% coinsurance for therapeutic radiology.
Home Health Services See details
Home Health Services are covered under the Aetna Medicare Enhanced (PPO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are provided with no coinsurance under Aetna Medicare Enhanced (PPO), and while some services are covered, specific options like cardiac rehabilitation ($20 copay), intensive cardiac rehabilitation ($20 copay), pulmonary rehabilitation ($15 copay), and SET for PAD services ($25 copay) are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Aetna Medicare Enhanced (PPO) with no coinsurance, requiring a $10 daily copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, though a prior three-day inpatient hospital stay is not needed, and additional days beyond the standard 100 days are not covered.
Other Services See details
Aetna Medicare Enhanced (PPO) partially covers other services, providing benefits such as over-the-counter (OTC) items, annual wellness exams, screening mammographies, and additional colorectal cancer screenings (gFOBT and FIT) with no copay and no coinsurance. However, acupuncture and meal benefits are not covered, and the OTC benefit is limited to a $30 reimbursement every three months.
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