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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.
This summary reflects 2026 plan information. Where this plan continues in 2027, the full plan details page links to its 2027 benefits and costs.
Aetna Medicare Enhanced (PPO) is a PPO plan offered by Aetna Life Insurance Company available for the 2026 plan year to people living in Ventura County. 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 $102.00. 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 $250.00 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 that applies only to drugs in certain tiers. You pay this amount toward covered prescriptions in those tiers before the plan's cost sharing begins; drugs in the other tiers are not subject to the deductible. See the full plan details page for the tier table.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $6750.00 for in-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $6750.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
This plan has a Maximum Out-Of-Pocket cost of $8900.00 (in-network and out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $8900.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
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 a $615.00 prescription drug deductible before your initial coverage begins. Under this plan, Tier 1 preferred generic drugs have no copay at preferred pharmacies or through preferred mail order, while standard options require a $12.00 copay. Tier 2 standard generic drugs carry a 24% coinsurance, while Tier 3 preferred brand and Tier 4 non-preferred drugs require a 25% coinsurance. After your yearly out-of-pocket drug costs reach $2,100.00, you enter the catastrophic coverage phase where you pay nothing for covered Part D prescriptions. Additionally, individuals qualifying for the low-income subsidy can see their Part D premium reduced from $89.00 to $77.00.
Additional Benefits
The Aetna Medicare Enhanced (PPO) plan provides comprehensive coverage for essential medical services, often featuring no copays or low cost-sharing. Members pay no copay and no coinsurance for primary care visits, preventive services, and home health care. For hospital stays, inpatient care requires a $395 copay for the first five days and no copay thereafter, while emergency room visits carry a $130 copay that is waived upon admission. Vision and routine hearing services are covered with no copays or coinsurance, including up to $1,250 per ear annually for prescription hearing aids. Preventive dental care also has no copay, while comprehensive dental services require a 20% to 50% coinsurance up to a $1,000 annual limit. Diagnostic lab work and home health services require no copayments, though some services like dialysis and therapeutic radiology require a 20% coinsurance.
Inpatient Hospital See details
Inpatient hospital benefits are partially covered by Aetna Medicare Enhanced (PPO), requiring a $395 copay for days 1 through 5, no copay for days 6 through 90, and no coinsurance. Prior authorization is required, but upgrades, non-Medicare-covered stays, and additional days for psychiatric care are not covered.
Outpatient Services See details
Aetna Medicare Enhanced (PPO) covers outpatient services with no coinsurance, including outpatient hospital care with a $0 to $400 copay, observation stays for a $395 copay, and substance abuse sessions for a $40 copay. Ambulatory surgical center and outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
Aetna Medicare Enhanced (PPO) covers partial hospitalization benefits with a copay of either $70.00 or $145.00 and no coinsurance. Prior authorization is required for these covered services.
Ambulance and Transportation Services See details
Aetna Medicare Enhanced (PPO) partially covers ambulance and transportation services, as ambulance services are covered while transportation services to health-related locations are not covered. Ground ambulance services require a $300 copay and no coinsurance, while air ambulance services require a 20% coinsurance and no copay, with prior authorization required for both.
Emergency Services See details
Aetna Medicare Enhanced (PPO) covers emergency services with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services are covered with a $40 copay and no coinsurance, while worldwide emergency services are covered up to $250,000 with copays ranging from $130 to $300.
Primary Care See details
Primary Care benefits are partially covered by Aetna Medicare Enhanced (PPO), as podiatry services and routine chiropractic care are not covered. Primary care visits require no copay and no coinsurance, while other covered services like specialists, mental health, and therapies have copays ranging from no copay to $40 with no coinsurance, except for telehealth which has a 20% coinsurance and copays from no copay to $40.
Preventive Services See details
Preventive services are partially covered under Aetna Medicare Enhanced (PPO), featuring no copays or coinsurance for annual physicals, health education, fitness benefits, and routine screenings. Kidney disease education is covered with a 20% coinsurance and no copay, but sub-services such as in-home safety assessments, PERS, medical nutrition therapy, medication reconciliation, re-admission prevention, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, palliative care, in-home support, caregiver support, disease management, telemonitoring, safety devices, and counseling are not covered.
Hearing Services See details
Aetna Medicare Enhanced (PPO) partially covers hearing services, providing routine hearing exams and fitting evaluations with no copay and no coinsurance. Prescription hearing aids are covered up to $1,250 per ear annually with no copay and no coinsurance, but OTC hearing aids, as well as inner ear, outer ear, and over the ear prescription hearing aids, are not covered.
Vision Services See details
Aetna Medicare Enhanced (PPO) covers vision services with no copays and no coinsurance for both eye exams and eyewear. The plan provides up to a $50 annual maximum for eye exams and a combined $100 annual limit for eyewear, including contacts, lenses, frames, and upgrades.
Dental Services See details
Dental services are partially covered under Aetna Medicare Enhanced (PPO), with no coverage for fluoride treatments, maxillofacial prosthetics, implant services, or orthodontics. Preventive care like oral exams and cleanings has no copay and no coinsurance, while Medicare-covered dental services require a $35 copay and no coinsurance, and other comprehensive services have no copay and 20% to 50% coinsurance up to a $1,000 annual maximum.
Home Infusion bundled Services See details
Home Infusion bundled Services are partially covered by Aetna Medicare Enhanced (PPO) because Part D home infusion drugs are not covered as a mandatory supplemental benefit. Covered services require prior authorization and feature a $35 copay for Medicare Part B insulin drugs and no coinsurance to 20% coinsurance for Part B chemotherapy, radiation, and other Part B drugs.
Dialysis Services See details
Dialysis Services are covered by Aetna Medicare Enhanced (PPO) with a 20% coinsurance and no copay. Prior authorization is required to receive these services.
Medical Equipment See details
Aetna Medicare Enhanced (PPO) covers medical equipment, including durable medical equipment, prosthetic devices, and diabetic supplies, with prior authorization required. There is no copay for these benefits, and coinsurance ranges from no coinsurance up to 20% depending on the specific service or item.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Aetna Medicare Enhanced (PPO) with prior authorization required. Lab services have no copay, outpatient X-rays require a $40 copay, diagnostic tests and radiology range from no copay up to $40 and $295 respectively, and therapeutic radiology requires a 20% coinsurance with no coinsurance for all other services.
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) does not cover Cardiac Rehabilitation Services, as all sub-services—including cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation—are not covered. Since these services are not covered, there is no copay and no coinsurance required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are partially covered by Aetna Medicare Enhanced (PPO) with prior authorization, requiring a $10 copay for days 1 to 20 and a $218 copay for days 21 to 100 with no coinsurance. Additional days beyond Medicare-covered SNF stays are not covered by the plan.
Other Services See details
Other Services are partially covered by Aetna Medicare Enhanced (PPO), which offers annual wellness exams, screening mammography, and additional gFOBT and FIT screenings with no copay and no coinsurance. Acupuncture, over-the-counter items, meal benefits, and dual-eligible SNP services are not covered under this plan.
Plan Providers
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, Health Care Service Corporation, HealthSpringSM, HealthSun, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
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1-877-649-2073 / TTY 711. Call-center hours (ET): Mon-Fri 8am-10pm; Sat 9am-8pm; Sun closed.
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