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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 MI Southwest. 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 $15.00. 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 $10100.00 (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 $10100.00 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 can save significantly by using preferred pharmacies or preferred mail-order services, which offer no copay for both Tier 1 preferred generics and Tier 2 generics. Standard pharmacies and standard mail-order options are also available but require copays starting at $2 for Tier 1 and $12 for Tier 2 drugs. Higher-tier medications under this plan transition to a coinsurance model for cost sharing. Tier 3 preferred brand-name drugs require a 24% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs carry a 25% coinsurance. These coinsurance rates apply across both preferred and standard pharmacies, helping you easily estimate your out-of-pocket prescription costs.
Additional Benefits
Aetna Medicare Enhanced (PPO) offers robust coverage for essential medical services with predictable out-of-pocket costs, featuring no copays or coinsurance for primary care visits and annual physicals. Specialist visits and outpatient diagnostic tests carry low copays, while inpatient hospital stays require a daily copay for the first six days followed by no copay for longer stays. Emergency services and home health care are also covered with minimal copays and no coinsurance. The plan also provides strong coverage for dental, vision, and hearing services, including no copays for routine exams and annual allowances for eyewear and hearing aids. Preventive dental care has no copay, while comprehensive dental services and durable medical equipment may require coinsurance up to 50 percent. Beneficiaries should note that transportation, acupuncture, and over-the-counter items are not covered under this plan.
Inpatient Hospital See details
Aetna Medicare Enhanced (PPO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $275 daily copay for days 1 through 6 and no copay for days 7 through 90. While unlimited additional acute care days are covered at no copay, additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient services covered by the Aetna Medicare Enhanced (PPO) feature no coinsurance, with no copays for ambulatory surgical center and outpatient blood services. Patients will pay a copay of $0 to $275 for outpatient hospital services, $275 per stay for observation services, and $40 per session for outpatient substance abuse services, with prior authorization required for most care.
Partial Hospitalization See details
Aetna Medicare Enhanced (PPO) covers partial hospitalization services with a copay of either $75.00 or $145.00 and no coinsurance. Prior authorization is required for these covered benefits.
Ambulance and Transportation Services See details
Aetna Medicare Enhanced (PPO) covers ambulance services with prior authorization, requiring a $250 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 under this plan.
Emergency Services See details
Aetna Medicare Enhanced (PPO) covers emergency services with a $130 copay and no coinsurance (waived if admitted within 24 hours), and urgently needed services with a $35 copay and no coinsurance. Worldwide emergency and urgent services are covered up to a $250,000 maximum with no coinsurance, requiring a $130 copay for emergency or urgent care and a $250 copay for emergency transportation.
Primary Care See details
Aetna Medicare Enhanced (PPO) offers primary care physician visits with no copay and no coinsurance, and specialist visits with a $0 to $40 copay and no coinsurance. Physical, occupational, and speech therapies are covered with a $30 copay and no coinsurance, while mental health, psychiatric, and opioid treatment services require a $40 copay and no coinsurance, though podiatry and routine chiropractic services are not covered.
Preventive Services See details
Aetna Medicare Enhanced (PPO) covers annual physicals, preventive screenings, and select wellness benefits with no copay and no coinsurance, while kidney disease education is covered with no copay and a 20% coinsurance. Additional preventive benefits are partially covered, excluding In-Home Safety Assessments, PERS, MNT, 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/bathroom safety devices, and counseling.
Hearing Services See details
Aetna Medicare Enhanced (PPO) covers hearing services with a $40 copay and no coinsurance for Medicare-covered exams, alongside annual routine exams and fitting evaluations at no copay and no coinsurance. Prescription hearing aids are partially covered up to $750 per ear every year with no copay or coinsurance, though inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
Aetna Medicare Enhanced (PPO) covers vision services with no deductibles and no coinsurance, offering eye exams with a $0 to $40 copay and eyewear with no copay. Beneficiaries receive one routine eye exam per year (up to $50) and a $125 annual combined maximum for eyewear, including contacts, lenses, and frames, all with no copays.
Dental Services See details
Aetna Medicare Enhanced (PPO) offers partially covered dental services, featuring no copay and no coinsurance for preventive care like cleanings and exams, and a $40 copay and no coinsurance for Medicare-covered dental. Comprehensive treatments like restorative and endodontics have no copay and 20% to 50% coinsurance up to a $1,250 annual maximum, though fluoride, 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 under the Aetna Medicare Enhanced (PPO) plan with no copay, though prior authorization is required. Under this benefit, Medicare Part B insulin has a $35 copay and no coinsurance, while Part B chemotherapy, radiation, and other Part B drugs require a 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the Aetna Medicare Enhanced (PPO) with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
Medical equipment is covered under Aetna Medicare Enhanced (PPO) with no copays and coinsurance ranging from no coinsurance to 20% for durable medical equipment, prosthetics, and diabetic supplies. Prior authorization is required for these services, and diabetic supplies are limited to specified manufacturers.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Aetna Medicare Enhanced (PPO) with prior authorization required. Outpatient diagnostic tests have no coinsurance and a $0 to $75 copay, lab services have no copay, and radiological services require a $15 copay for X-rays, copays starting at $0 for diagnostic radiology, and a minimum 20% coinsurance for therapeutic radiological services.
Home Health Services See details
Home Health Services are covered under Aetna Medicare Enhanced (PPO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are offered by Aetna Medicare Enhanced (PPO) with no coinsurance, and although some services are covered, specific programs 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
Aetna Medicare Enhanced (PPO) covers Skilled Nursing Facility (SNF) services 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, prior hospital stays of less than three days are allowed, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other services are partially covered by Aetna Medicare Enhanced (PPO), which features no copay and no coinsurance for annual wellness exams, screening mammographies, and additional gFOBT and FIT screenings. Acupuncture, over-the-counter (OTC) items, and meal benefits are not covered under this plan.
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