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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 Sandhills and Southeastern NC. 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 $20.00. 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 $6900.00 (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 $6900.00 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 prescription drug deductible of $615. Under this plan, you will pay no copay for Tier 1 preferred generic and Tier 2 generic drugs when using a preferred pharmacy or preferred mail-order service. Standard pharmacies and standard mail-order options carry a low copay starting at $2 for Tier 1 and $12 for Tier 2 for a one-month supply. For higher-tier medications, costs are based on coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 24% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs both carry a 25% coinsurance. Specialty drugs are limited to a one-month supply under these cost-sharing terms.
Additional Benefits
The Aetna Medicare Enhanced (PPO) plan provides strong foundational coverage with no copay and no coinsurance for primary care visits, routine preventive services, and home health care. Specialist visits feature a copay ranging from $0 to $40, while inpatient hospital stays require daily copays for the first eight days with no coinsurance. Outpatient hospital services and diagnostic tests are also covered with no coinsurance and varying copays. Ancillary benefits include routine dental, hearing, and vision exams with no copay, plus a $1,250 annual prescription hearing aid allowance per ear. Emergency care is covered worldwide with a $130 copay that is waived upon hospital admission, and urgent care carries a $50 copay. Members also benefit from no copays on medical equipment and a $30 quarterly allowance for over-the-counter health items.
Inpatient Hospital See details
Aetna Medicare Enhanced (PPO) covers inpatient hospital services with no coinsurance, requiring a $382 daily copay for days 1 to 8 of acute stays and a $292 daily copay for days 1 to 8 of psychiatric stays, with no copay for subsequent days. Prior authorization is required, and some services such as 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, though prior authorization is required for outpatient hospital, observation, surgical, and substance abuse services. Patients will pay a $40 copay for outpatient substance abuse sessions, $0 to $382 for outpatient hospital and observation services, and no copay for ambulatory surgical center and outpatient blood services.
Partial Hospitalization See details
Partial hospitalization benefits are 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
Aetna Medicare Enhanced (PPO) covers ambulance services with prior authorization, requiring a $275 copay and no coinsurance for ground ambulance services, and a 20% coinsurance with no copay for air ambulance services. Transportation services to health-related locations are not covered.
Emergency Services See details
Emergency services under the Aetna Medicare Enhanced (PPO) are covered with a $130 copay—waived if admitted to the hospital within 24 hours—and no coinsurance, while urgent care has a $50 copay and no coinsurance. Worldwide emergency and urgent services are covered up to $250,000 with no coinsurance, requiring a $130 copay for care and a $275 copay for transportation, with no costs counting toward the plan deductible.
Primary Care See details
Primary care services under the Aetna Medicare Enhanced (PPO) are covered with no copay and no coinsurance for primary care visits, while specialist visits require a $0 to $40 copay and no coinsurance. Physical, occupational, mental health, and psychiatric therapies are covered with copays ranging from $35 to $40 and no coinsurance, whereas chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive Services under the Aetna Medicare Enhanced (PPO) are partially covered, offering annual physical exams, health education, fitness benefits, and screenings with no copay and no coinsurance, while kidney disease education has no copay and a 20% coinsurance. Sub-services not covered 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, disease management, telemonitoring, home safety devices, and counseling.
Hearing Services See details
Hearing services are partially covered by Aetna Medicare Enhanced (PPO), featuring a $40 copay and no coinsurance for Medicare-covered exams, and no copay or coinsurance for annual routine exams and fitting evaluations. Prescription hearing aids are covered up to $1,250 per ear annually with no copay or coinsurance, while over-the-counter (OTC) hearing aids and inner, outer, 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, including eye exams with a $0 to $40 copay and eyewear with no copay. Covered benefits are subject to annual maximums of $50 for eye exams and a combined $100 for contacts and eyeglasses.
Dental Services See details
Dental services are partially covered by the Aetna Medicare Enhanced (PPO) plan, offering preventive care like exams and cleanings with no copay and no coinsurance, and Medicare-covered dental services for a $40 copay and no coinsurance. Comprehensive dental services require no copay and 20% to 50% coinsurance up to a $1,500 annual limit, though fluoride treatments, implants, orthodontics, maxillofacial prosthetics, and other diagnostic or preventive services are not covered.
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 insulin drugs require a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs have no copay and a 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Aetna Medicare Enhanced (PPO) plan with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
Aetna Medicare Enhanced (PPO) covers medical equipment, including durable medical equipment, prosthetics, and diabetic supplies, with no copays. Coinsurance for these covered items ranges from no coinsurance up to 20%, and prior authorization is required.
Diagnostic and Radiological Services See details
Aetna Medicare Enhanced (PPO) covers diagnostic and radiological services, with prior authorization required for all services. Diagnostic procedures and tests have a copay ranging from $0 to $200 with no coinsurance, therapeutic radiology requires 20% coinsurance, and lab services, outpatient X-rays, and diagnostic radiology have no copay.
Home Health Services See details
Aetna Medicare Enhanced (PPO) covers home health services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Aetna Medicare Enhanced (PPO) covers Cardiac Rehabilitation Services with no coinsurance, but only some services are covered. Specifically, cardiac rehabilitation ($20 copay), intensive cardiac rehabilitation ($20 copay), pulmonary rehabilitation ($15 copay), and supervised exercise therapy (SET) for symptomatic peripheral artery disease ($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, a prior three-day hospital stay is not needed for admission, and additional days beyond the standard 100 days are not covered.
Other Services See details
Aetna Medicare Enhanced (PPO) partially covers other services with no copay and no coinsurance, providing benefits for annual wellness exams, screening mammographies, and up to $30 every three months in over-the-counter (OTC) item reimbursements. Acupuncture and meal benefits are not covered.
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