A non-government entity
Aetna Medicare Prime Premier (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare Prime Premier (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 Premier (PPO) in 2025, please refer to our full plan details page.
Aetna Medicare Prime Premier (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 2025.
It's important to know that Aetna Medicare Prime Premier (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 Premier (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 Premier (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $39.00. 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 $590.00 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 $14000.00 (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 $14000.00 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:
Sign up for Aetna Medicare Prime Premier (PPO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The Aetna Medicare Prime Premier (PPO) plan has a $590 deductible for prescription drugs. Once you meet your deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For example, preferred generic drugs have no copay at preferred pharmacies, while standard generic drugs have 24% coinsurance. After your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs. If you qualify for the low-income subsidy, you will pay $39 per month for Part D.
Additional Benefits
The Aetna Medicare Prime Premier (PPO) plan offers comprehensive coverage with varying cost-sharing options. Hospital stays include a copay, with costs varying depending on the type of service and length of stay. Outpatient services, including primary care and specialist visits, often have no copay or a small copay, and other services such as preventive care, hearing, vision, and dental services have varying copays and coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you pay a $325 copay for days 1-5, and no copay for days 6-90; for Inpatient Hospital Psychiatric, you pay a $339 copay for days 1-6, and no copay for days 7-90. Additional days for Inpatient Hospital-Acute are covered with no copay, but the Non-Medicare-covered stay and Upgrades for Inpatient Hospital-Acute are not covered; the Additional Days and Non-Medicare-covered stay for Inpatient Hospital Psychiatric are also not covered.
Outpatient Services See details
The Aetna Medicare Prime Premier (PPO) plan covers outpatient services, including all outpatient hospital services, with a copay between $0 and $375. Observation services have a $325 copay, while Ambulatory Surgical Center (ASC) Services have no copay. Outpatient Substance Abuse Services have a $40 copay for both individual and group sessions, and Outpatient Blood Services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Aetna Medicare Prime Premier (PPO) plan. You will have a $60 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Aetna Medicare Prime Premier (PPO) plan. Both ground and air ambulance services have a $300 copay, with no coinsurance, while transportation services to health-related locations are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Aetna Medicare Prime Premier (PPO) plan. Emergency Services and Worldwide Emergency Coverage have a $110 copay, Urgently Needed Services have a $45 copay, and Worldwide Emergency Transportation has a $300 copay, with no coinsurance for any of these services.
Primary Care See details
The Aetna Medicare Prime Premier (PPO) plan covers primary care physician services with no copay, chiropractic services with a $15 copay, occupational therapy services with a $25 copay, physician specialist services with a copay between $0 and $35, and physical therapy/speech-language pathology services with a $25 copay. Mental health and psychiatric services have a $40 copay for individual or group sessions, and Opioid Treatment Program Services has a $40 copay. Additional telehealth benefits have a 20% coinsurance and a copay between $0 and $45. Podiatry services are not covered.
Preventive Services See details
The Aetna Medicare Prime Premier (PPO) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services such as health education, wigs for hair loss related to chemotherapy, nutritional/dietary benefits, additional sessions of smoking and tobacco cessation counseling, remote access technologies, and fitness benefits are covered with no copay, while kidney disease education services have a 20% coinsurance.
Hearing Services See details
Hearing Services include hearing exams, routine hearing exams, fitting/evaluation for hearing aids, prescription hearing aids, and OTC hearing aids. Hearing exams have a $35 copay, while routine hearing exams and fitting/evaluation for hearing aids have no copay, and prescription hearing aids have a copay of up to $1700 depending on the type of hearing aid. OTC hearing aids, and prescription hearing aids for the inner ear, outer ear, and over the ear are not covered.
Vision Services See details
The Aetna Medicare Prime Premier (PPO) plan covers vision services, including eye exams with a copay between $0 and $35, and eyewear with no copay, with a combined maximum of $150 per year. Routine eye exams have no copay and are limited to one per year, while other eye exam services are unlimited and have no copay.
Dental Services See details
The Aetna Medicare Prime Premier (PPO) plan covers Medicare dental services with a $35 copay, and other dental services with a $1,000 maximum benefit per year. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are covered with no copay. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required for these services.
Dialysis Services See details
Dialysis Services are covered under the Aetna Medicare Prime Premier (PPO) plan, but require prior authorization. The coinsurance for these services is 20%.
Medical Equipment See details
Medical Equipment benefits include coverage for Durable Medical Equipment (DME) with a coinsurance between 0% and 20%, and Prosthetic Devices with a 20% coinsurance. Diabetic Supplies have a coinsurance between 0% and 20%, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including diagnostic procedures/tests, lab services, and radiological services, are covered. Diagnostic procedures and tests have a copay between $0 and $35, while lab services have no copay. Diagnostic radiological services have a copay up to $250, while therapeutic radiological services have a 20% coinsurance, and outpatient X-rays have a $35 copay.
Home Health Services See details
Home Health Services are covered by the Aetna Medicare Prime Premier (PPO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the Aetna Medicare Prime Premier (PPO) plan, but the specific services are not covered. The plan mentions that the copay information is available below, but does not specify the cost of the services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Aetna Medicare Prime Premier (PPO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $205 per day; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The Aetna Medicare Prime Premier (PPO) plan does not cover acupuncture, over-the-counter items, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, or Self-Directed Personal Assistance Services. The plan covers meal benefits with no copay. Other services covered include annual wellness exams, screening mammography, and gFOBT/FIT with no copay.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved