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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 Midlands South 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 $29.00. 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 $9750.00 (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 $9750.00 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) prescription drug plan features an annual drug deductible of $615. For Tier 1 preferred generic and Tier 2 generic medications, members enjoy no copay when utilizing preferred pharmacies or preferred mail-order services. If you use standard pharmacies or standard mail order, copays start at $2 for Tier 1 and $12 for Tier 2 drugs. Brand-name and specialty medications under this plan require coinsurance instead of flat copays. Tier 3 preferred brand drugs incur a 24% coinsurance, while Tier 4 non-preferred and Tier 5 specialty drugs carry a 25% coinsurance across all pharmacy types. These clear cost-sharing tiers make it easy to estimate your out-of-pocket prescription costs.
Additional Benefits
The Aetna Medicare Enhanced (PPO) plan offers robust coverage for everyday healthcare needs, featuring no copay and no coinsurance for primary care visits, annual physicals, and home health services. Specialist visits range from no copay to a $45 copay with no coinsurance, while inpatient hospital stays require a daily copay of $388 for the first seven days of acute care. Emergency room visits carry a $115 copay, which is waived if you are admitted, while urgent care visits require a $40 copay. For additional wellness benefits, the plan provides preventive dental, routine vision, and annual hearing exams with no copay and no coinsurance. Comprehensive dental services are covered with no copay and 20% to 50% coinsurance up to a $1,000 annual limit, while prescription hearing aids are covered up to $500 per ear annually with no copay. Additionally, members receive a $30 quarterly allowance for over-the-counter items with no copay and no coinsurance.
Inpatient Hospital See details
Inpatient hospital services under the Aetna Medicare Enhanced (PPO) are partially covered with no coinsurance, requiring prior authorization and a daily copay of $388 for days 1–7 of acute stays and $260 for days 1–8 of psychiatric stays. While unlimited additional acute days are covered at no copay, additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Aetna Medicare Enhanced (PPO) covers outpatient services with no coinsurance, featuring no copays for ambulatory surgical center and outpatient blood services. Medicare-covered outpatient hospital services require a copay ranging from $0 to $388, observation services cost a $388 copay per stay, and outpatient substance abuse sessions have a $40 copay.
Partial Hospitalization See details
Aetna Medicare Enhanced (PPO) covers partial hospitalization services with a copay of $105.00 or $110.00 and no coinsurance. Prior authorization is required for these covered benefits.
Ambulance and Transportation Services See details
Aetna Medicare Enhanced (PPO) covers ground ambulance services with a $275 copay and air ambulance services with a 20% coinsurance, both requiring prior authorization. Transportation services to plan-approved or other health-related locations are not covered.
Emergency Services See details
Aetna Medicare Enhanced (PPO) covers emergency services with a $115 copay and no coinsurance (waived if admitted within 24 hours), and urgent care with a $40 copay and no coinsurance, with neither service counting toward the plan deductible. Worldwide emergency services are covered up to a $250,000 maximum benefit with no coinsurance, requiring a $115 copay for emergency or urgent care and a $275 copay for emergency transportation.
Primary Care See details
Aetna Medicare Enhanced (PPO) offers primary care physician services with no copay and no coinsurance, and specialist visits with a $0 to $45 copay and no coinsurance. Physical, occupational, and speech therapies require a $35 copay, while mental health, psychiatric, and opioid treatment services have a $40 copay, all with no coinsurance. Telehealth services require a $0 to $40 copay and 20% coinsurance, podiatry is not covered, and while some chiropractic services are covered with a $15 copay and no coinsurance, routine and other chiropractic services are not.
Preventive Services See details
Aetna Medicare Enhanced (PPO) offers preventive services with no copay and no coinsurance for annual physicals, fitness benefits, and screenings, though kidney disease education requires a 20% coinsurance and no copay. The benefit is partially covered, as it does not cover 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/bathroom safety devices, and counseling.
Hearing Services See details
Hearing services are partially covered by Aetna Medicare Enhanced (PPO), featuring a $45 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 $500 per ear annually with no copay or coinsurance, though OTC, inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
Aetna Medicare Enhanced (PPO) covers vision services with no deductibles and no coinsurance, featuring a $0 to $45 copay for eye exams and no copay for eyewear. Routine eye exams, follow-up diabetic eye exams, and eyewear like contacts, lenses, and frames are covered with no copay, up to a $50 annual limit for exams and a $100 annual combined limit for eyewear.
Dental Services See details
Dental services are partially covered under Aetna Medicare Enhanced (PPO), offering preventive care like exams and cleanings with no copay and no coinsurance, and Medicare-covered dental with a $45 copay and no coinsurance. Comprehensive services are covered with no copay and 20% to 50% coinsurance up to a $1,000 yearly limit, while fluoride, implants, orthodontics, maxillofacial prosthetics, and other diagnostic or 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 and step therapy may apply. Under this benefit, covered Part B chemotherapy and other drugs require a 0% to 20% coinsurance and no copay, 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 to receive these services.
Medical Equipment See details
Aetna Medicare Enhanced (PPO) covers medical equipment, including durable medical equipment, prosthetics, and medical supplies, with no copays and coinsurance ranging from no coinsurance to 20%. Covered diabetic equipment and supplies, including diabetic therapeutic shoes and inserts, also feature no copays and coinsurance ranging from no coinsurance to 20%.
Diagnostic and Radiological Services See details
Aetna Medicare Enhanced (PPO) covers diagnostic and radiological services, with prior authorization required for all services. Lab services have no copay and no coinsurance, while diagnostic procedures and tests have no coinsurance and a copay ranging from $0 to $200. Diagnostic radiological services have copays starting at $0 with no coinsurance, outpatient X-rays have no copay but require coinsurance, and therapeutic services require a copay and at least 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 not covered under the Aetna Medicare Enhanced (PPO) plan, as cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are all not covered.
Skilled Nursing Facility (SNF) See details
Skilled nursing facility (SNF) care is covered by Aetna Medicare Enhanced (PPO) with no coinsurance, featuring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required and a prior three-day hospital stay is not necessary, though additional days beyond the standard 100-day Medicare benefit are not covered.
Other Services See details
Aetna Medicare Enhanced (PPO) partially covers other services, offering no copay and no coinsurance for over-the-counter (OTC) items up to $30 every three months, annual wellness exams, screening mammography, and additional gFOBT and FIT. Acupuncture and meal benefits are not covered under this plan.
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