A non-government entity
Aetna Medicare Premier (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare 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 Premier (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 Premier (PPO) is a PPO plan offered by Aetna Life Insurance Company available for the 2026 plan year to people living in Central Upstate NY 1. This plan received an overall rating of 4.5 out of 5 stars in 2026.
It's important to know that Aetna Medicare 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 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 Premier (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $50.00. 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 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 $8900.00 for in-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $8900.00 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 $13900.00 (in-network and out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $13900.00 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 Premier (PPO) prescription drug plan features an annual drug deductible of $615. For Tier 1 preferred generics and Tier 2 generics, members enjoy no copay when using preferred pharmacies or preferred mail-order services. If using standard pharmacies or standard mail order, Tier 1 copays range from $2 to $6, while Tier 2 copays range from $12 to $36 depending on the supply length. For higher-tier medications, costs are based on coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 24% coinsurance at both preferred and standard pharmacies or mail-order options. Tier 4 non-preferred drugs and Tier 5 specialty drugs both carry a 25% coinsurance, with specialty medications limited to a one-month supply.
Additional Benefits
The Aetna Medicare Premier (PPO) plan offers affordable coverage for core medical services, featuring no copays for primary care doctor visits and routine preventive screenings. Specialist visits require a copay of up to $35, while emergency room care carries a $115 copay that is waived upon hospital admission. For inpatient hospital stays, members pay a daily copay for the first six days of care, followed by no copay for the remainder of their stay. This plan also includes valuable extra benefits, such as comprehensive dental coverage with no copay up to a $1,500 annual limit. Routine vision and hearing exams are available with no copay, alongside coverage for eyewear and hearing aids. Additionally, members benefit from home health services with no copay and a $30 quarterly allowance for over-the-counter health items.
Inpatient Hospital See details
Aetna Medicare Premier (PPO) partially covers inpatient hospital services with no coinsurance, featuring a $325 daily copay for days 1 through 6 of acute stays and a $340 daily copay for days 1 through 6 of psychiatric stays, followed by no copay for remaining covered days. Upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Aetna Medicare Premier (PPO) covers outpatient services with no coinsurance, featuring no copay for ambulatory surgical center and blood services. Patients will pay a copay of $0 to $325 for outpatient hospital services, $325 per stay for observation services, and $35 for outpatient substance abuse sessions.
Partial Hospitalization See details
Aetna Medicare Premier (PPO) covers partial hospitalization services with a copay of $80.00 or $110.00 and no coinsurance. Prior authorization is required for these covered services.
Ambulance and Transportation Services See details
Aetna Medicare Premier (PPO) covers Medicare-covered ground and air ambulance services with a $300 copay and no coinsurance, subject to prior authorization. Transportation services, including trips to plan-approved or any health-related locations, are not covered.
Emergency Services See details
Emergency services are covered by Aetna Medicare Premier (PPO) with a $115 copay and no coinsurance, which is waived if admitted to the hospital within 24 hours, and urgent care is covered with a $40 copay and no coinsurance. Worldwide emergency services are also covered up to a $250,000 maximum with no coinsurance, carrying a $115 copay for emergency or urgent care and a $300 copay for emergency transportation.
Primary Care See details
Aetna Medicare Premier (PPO) provides primary care physician services with no copay and no coinsurance, while specialist visits and therapy services have copays ranging from $0 to $35 and no coinsurance. Telehealth benefits are covered with a $0 to $40 copay and 20% coinsurance, though chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive services are partially covered by Aetna Medicare Premier (PPO), featuring no copay and no coinsurance for annual physicals and screenings, and a 20% coinsurance with no copay for kidney disease education. Sub-services not covered include 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 benefits, palliative care, in-home support, caregiver support, disease management, telemonitoring, safety devices, and counseling.
Hearing Services See details
Aetna Medicare Premier (PPO) covers hearing services with no deductible, offering Medicare-covered exams for a $35 copay and routine exams or fittings with no copay, all with no coinsurance. Prescription hearing aids are partially covered with no coinsurance and a copay between $0 and $1,700 for up to two aids per year, while OTC hearing aids and inner ear, outer ear, and over the ear prescription models are not covered.
Vision Services See details
Vision Services are covered by Aetna Medicare Premier (PPO) with no deductible and no coinsurance, offering eye exams with a $0 to $35 copay and eyewear with no copay. Routine eye exams are covered up to a $50 annual maximum (one visit per year), and a combined maximum of $150 per year is provided for contact lenses, eyeglasses, frames, lenses, and upgrades.
Dental Services See details
Aetna Medicare Premier (PPO) partially covers dental services up to a $1,500 annual maximum for both in-network and out-of-network care, excluding maxillofacial prosthetics, implant services, and orthodontics. Medicare-covered dental services require a $35 copay and no coinsurance, while other covered preventive and comprehensive services are available with no copay and no coinsurance.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Aetna Medicare Premier (PPO) with no copay, though prior authorization is required. Under this benefit, Medicare Part B insulin is covered with a $35 copay and no coinsurance, while Part B chemotherapy and other drugs require no copay and a 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Aetna Medicare Premier (PPO) plan with no copay and a 20% coinsurance, although prior authorization is required.
Medical Equipment See details
Aetna Medicare Premier (PPO) covers medical equipment, including durable medical equipment, prosthetics, and diabetic supplies, with no copay and coinsurance ranging from no coinsurance to 20%. Prior authorization is required for these services, and diabetic supplies are limited to specified manufacturers.
Diagnostic and Radiological Services See details
Aetna Medicare Premier (PPO) covers diagnostic and radiological services, requiring prior authorization for these benefits. Diagnostic procedures and tests have no coinsurance and a copay of $0 to $35, lab and diagnostic radiological services have no copay, outpatient X-rays require a $35 copay, and therapeutic radiological services carry a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered under the Aetna Medicare Premier (PPO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Aetna Medicare Premier (PPO) covers some cardiac rehabilitation services with no coinsurance, but key services are not covered. Specifically, standard cardiac rehabilitation ($20 copay), intensive cardiac rehabilitation ($20 copay), pulmonary rehabilitation ($15 copay), and supervised exercise therapy for peripheral artery disease ($20 copay) are not covered.
Skilled Nursing Facility (SNF) See details
Aetna Medicare Premier (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but not requiring a prior three-day inpatient hospital stay. There is no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, though additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Aetna Medicare Premier (PPO) covers several additional services with no copay and no coinsurance, including a $30 quarterly over-the-counter item allowance, chronic illness meals, annual wellness exams, and additional colorectal cancer screenings. Acupuncture is 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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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.
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