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Aetna Medicare Prime Extra (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare Prime Extra (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Aetna Medicare Prime Extra (PPO) in 2026, please refer to our full plan details page.
Aetna Medicare Prime Extra (PPO) is a PPO plan offered by CVS Health Corporation available for enrollment in 2025 to people living in Counties: BR, HT, MR, MN, MO, PS, SM, SX, UN, WR. This plan received an overall rating of 4.5 out of 5 stars in 2026.
It's important to know that Aetna Medicare Prime Extra (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 Prime Extra (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 Prime Extra (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $74.00. 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 $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 $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 Prime Extra (PPO) prescription drug plan features an annual deductible of $615. 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. For standard pharmacies and standard mail-order options, Tier 1 copays range from $2 to $6, while Tier 2 copays range from $12 to $36 depending on the supply. For brand-name and specialty medications, the plan requires coinsurance instead of flat copays. Tier 3 preferred brand drugs carry a 24% coinsurance, while Tier 4 non-preferred drugs require a 25% coinsurance. Tier 5 specialty drugs also require a 25% coinsurance and are limited to a 1-month supply.
Additional Benefits
The Aetna Medicare Prime Extra (PPO) plan offers comprehensive coverage with no deductibles and numerous services featuring no copays. You will pay no copay and no coinsurance for primary care doctor visits, annual physicals, routine hearing exams, and home health services, while specialist visits range from no copay to a $35 copay. For hospital care, emergency room visits require a $115 copay which is waived upon admission, and inpatient acute stays carry a $350 daily copay for the first five days with no copay for subsequent days. Ancillary benefits under this plan include preventive and comprehensive dental services, routine vision exams, and eyewear with no copays or coinsurance, subject to plan maximums. Skilled nursing facility stays are covered with no copay for the first 20 days and a $218 daily copay for days 21 through 100. Diagnostic lab tests and home infusion services also feature no copays, while dialysis and Medicare Part B drugs require a coinsurance of up to 20%.
Inpatient Hospital See details
Aetna Medicare Prime Extra (PPO) covers inpatient hospital services with no coinsurance, but requires prior authorization. For acute stays, there is a $350 daily copay for days 1-5 and no copay for days 6 and beyond, whereas psychiatric stays require a $346 daily copay for days 1-6 and no copay for days 7-90. This benefit is partially covered, as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Aetna Medicare Prime Extra (PPO) covers outpatient services with no coinsurance, including ambulatory surgical center and blood services which both feature no copays. Outpatient hospital services require a copay of $0 to $375, observation services carry a $350 copay per stay, and outpatient substance abuse sessions have a $35 copay.
Partial Hospitalization See details
Aetna Medicare Prime Extra (PPO) covers partial hospitalization services with a copay of $60.00 or $110.00 and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
Aetna Medicare Prime Extra (PPO) covers ground and air ambulance services with a $300 copay and no coinsurance, subject to prior authorization. Non-emergency transportation services, including trips to plan-approved or any health-related locations, are not covered.
Emergency Services See details
Aetna Medicare Prime Extra (PPO) covers emergency services with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours, and urgently needed services with a $40 copay and no coinsurance. Worldwide emergency, urgent, and transportation services are also covered with no coinsurance and copays ranging from $115 to $300, up to a maximum plan benefit of $250,000.
Primary Care See details
Primary care services are covered by Aetna Medicare Prime Extra (PPO) with no copay and no coinsurance for primary care visits, and a $0 to $35 copay with no coinsurance for specialists. Physical and occupational therapy require a $25 copay with no coinsurance, while podiatry is not covered and chiropractic services are only partially covered, with routine and other chiropractic services excluded.
Preventive Services See details
Preventive Services under the Aetna Medicare Prime Extra (PPO) are partially covered, offering annual physicals, select screenings, and fitness benefits with no copay and no coinsurance, while kidney disease education has 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
Hearing services are covered by Aetna Medicare Prime Extra (PPO), featuring a $35 copay and no coinsurance for Medicare-covered exams, and no copay or coinsurance for annual routine exams and fitting evaluations. Prescription hearing aids are partially covered with no coinsurance and a copay ranging from $0 to $1,700 for up to two devices per year, though OTC, inner ear, outer ear, and over-the-ear hearing aids are not covered.
Vision Services See details
Aetna Medicare Prime Extra (PPO) covers vision services with no deductibles and no coinsurance, including eye exams with a $0 to $35 copay and eyewear with no copay. Routine eye exams are limited to one per year with a $50 annual maximum, while contacts, eyeglasses, frames, and upgrades are covered up to a combined annual limit of $100.
Dental Services See details
Dental Services are partially covered by Aetna Medicare Prime Extra (PPO), which offers Medicare-covered dental services for a $35 copay and no coinsurance, and other covered preventive and comprehensive dental services with no copay and no coinsurance up to a $750 annual maximum. However, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Aetna Medicare Prime Extra (PPO) covers Home Infusion bundled Services with no copay, though prior authorization and step therapy are required. Under this benefit, Medicare Part B insulin is covered with a $35 copay and no coinsurance, while chemotherapy and other Part B drugs require a 0% to 20% coinsurance and no copay.
Dialysis Services See details
Dialysis services are covered under Aetna Medicare Prime Extra (PPO) with no copay and a 20% coinsurance. Prior authorization is required to receive these services.
Medical Equipment See details
Medical equipment is covered by Aetna Medicare Prime Extra (PPO) with no copay and coinsurance ranging from 0% to 20%, depending on the specific item. This coverage includes durable medical equipment, prosthetics, and diabetic supplies, all of which require prior authorization.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Aetna Medicare Prime Extra (PPO), with lab services requiring no copay or coinsurance, and diagnostic tests carrying a $0 to $35 copay with no coinsurance. Diagnostic radiological services feature a $0 minimum copay, while therapeutic radiological services require a minimum 20% coinsurance, and outpatient X-rays require a $35 copay with coinsurance.
Home Health Services See details
Aetna Medicare Prime Extra (PPO) covers Home Health Services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Aetna Medicare Prime Extra (PPO) provides cardiac rehabilitation services with no coinsurance, but only some services are covered in practice. Specifically, cardiac rehabilitation, intensive cardiac rehabilitation, and supervised exercise therapy for peripheral artery disease (each with a $20 copay), along with pulmonary rehabilitation (with a $15 copay), are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Aetna Medicare Prime Extra (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, though a prior three-day inpatient hospital stay is not, and additional days beyond the standard 100-day benefit period are not covered.
Other Services See details
Aetna Medicare Prime Extra (PPO) partially covers other services, offering a chronic illness 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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