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Aetna Medicare Essential (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare Essential (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Aetna Medicare Essential (PPO) in 2025, please refer to our full plan details page.
Aetna Medicare Essential (PPO) is a PPO plan offered by CVS Health Corporation available for enrollment in 2025 to people living in Eastern and Sandhills NC. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Aetna Medicare Essential (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 Essential (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 Essential (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $35.00. You must continue to pay paying your reduced 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 $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 $8500.00 (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 $8500.00 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 Essential (PPO) plan has a $590.00 deductible for prescription drugs. After meeting the deductible, you'll pay a copay or coinsurance depending on the drug tier and pharmacy you use. For preferred generic drugs, there is no copay at preferred pharmacies and mail order, and a $12 copay at standard pharmacies. Standard generic drugs, preferred brand drugs, and non-preferred drugs all have 24% or 25% coinsurance. Once your total drug costs reach $2000.00, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs.
Additional Benefits
The Aetna Medicare Essential (PPO) plan offers comprehensive coverage with varying costs depending on the service. You'll find no copay for many services, including primary care visits, preventive services like annual physicals and screenings, and dental services. However, you may encounter copays for services like inpatient hospital stays, outpatient services, ambulance services, and specialist visits, as well as coinsurance for services like dialysis and durable medical equipment.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, with prior authorization required. For Inpatient Hospital-Acute, you pay a $332 copay for days 1-8, and no copay for days 9-90; for Inpatient Hospital Psychiatric, the copay is $254 for days 1-8, and no copay for days 9-90. Additional days for Inpatient Hospital-Acute are covered with no copay, while Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, are covered under the Aetna Medicare Essential (PPO) plan. Outpatient Hospital Services have a copay between $0 and $332, and Observation Services have a copay of $332. Ambulatory Surgical Center (ASC) Services and Outpatient Blood Services have no copay, and Outpatient Substance Abuse Services have a $40 copay for both individual and group sessions.
Partial Hospitalization See details
Partial Hospitalization is covered by the Aetna Medicare Essential (PPO) plan, but requires prior authorization. The plan has an $80 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Aetna Medicare Essential (PPO) plan, with a $275 copay for ground ambulance services and 20% coinsurance for air ambulance services. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Aetna Medicare Essential (PPO) plan. Emergency Services have a $110 copay, Urgently Needed Services have a $45 copay, Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $110 copay, and Worldwide Emergency Transportation has a $275 copay. Worldwide Emergency Services has a maximum benefit coverage of $250,000.
Primary Care See details
Primary Care benefits include coverage for Primary Care Physician Services with no copay, Chiropractic Services with a $15 copay (routine care not covered), Occupational Therapy Services with a $30 copay, Physician Specialist Services with a copay between $0 and $45, Mental Health Specialty Services with a $40 copay for individual and group sessions, Other Health Care Professional services with a copay between $0 and $45, Psychiatric Services with a $40 copay for individual and group sessions, and Physical Therapy and Speech-Language Pathology Services with a $30 copay. Additional Telehealth benefits are covered with a 20% coinsurance and a copay between $0 and $45, and Opioid Treatment Program Services are covered with a $40 copay.
Preventive Services See details
Preventive Services include annual physical exams with no copay, and additional preventive services including Health Education, Additional Sessions of Smoking and Tobacco Cessation Counseling, Fitness Benefit, and Remote Access Technologies, with no copay. The plan also covers Kidney Disease Education Services with 20% coinsurance. Other preventive services such as Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit are covered with no copay.
Hearing Services See details
Hearing exams are covered under the Aetna Medicare Essential (PPO) plan for a $45 copay. Routine hearing exams and fitting/evaluation for hearing aids have no copay. Prescription hearing aids (all types) are covered with a maximum benefit of $1,250 per year. Prescription hearing aids - inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are also not covered.
Vision Services See details
Vision Services includes coverage for eye exams with a copay between $0 and $45, and routine eye exams and other eye exam services have no copay. Eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades, are covered with no copay, with a combined maximum benefit of $200 per year.
Dental Services See details
The Aetna Medicare Essential (PPO) plan covers dental services, including oral exams, dental x-rays, and other diagnostic dental services with no copay. Other covered services include prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery, all with no copay. However, the plan does not cover maxillofacial prosthetics, implant services, or orthodontics.
Home Infusion bundled Services See details
Home Infusion bundled Services, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs, are covered. Medicare Part B Insulin Drugs have a $35 copay. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered, but require prior authorization. The plan has a coinsurance of 20% for dialysis services.
Medical Equipment See details
Medical Equipment benefits are covered by the Aetna Medicare Essential (PPO) plan. Durable Medical Equipment (DME) has a coinsurance of 0% to 20%, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices have a 20% coinsurance, and Medical Supplies have a 0% to 20% coinsurance. Diabetic Equipment is covered, with Medicare-covered Diabetic Therapeutic Shoes or Inserts subject to coinsurance and Medicare-covered Diabetes Supplies subject to a copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including all diagnostic services, diagnostic procedures/tests, lab services, and radiological services. Diagnostic Procedures/Tests have a copay between $0 and $100, Lab Services have no copay, Diagnostic Radiological Services have a copay up to $300, Therapeutic Radiological Services have 20% coinsurance, and Outpatient X-Ray Services have a $14 copay.
Home Health Services See details
Home Health Services are covered by the Aetna Medicare Essential (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the Aetna Medicare Essential (PPO) plan, but the plan does not cover the specific services of Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services. There is a copay for some of these services, but the exact amount is not specified.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Aetna Medicare Essential (PPO) plan, but require prior authorization. You will have no copay for days 1-20, and a $214 copay per day for days 21-100. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services include coverage for Over-the-Counter (OTC) items and meal benefits with no copay, as well as coverage for other services like annual wellness exams, screening mammography, and gFOBT/FIT with no copay. Acupuncture, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and many other services are not covered.
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