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Aetna Medicare Prime (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare Prime (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 (PPO) in 2026, please refer to our full plan details page.
Aetna Medicare Prime (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 (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 (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 (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.
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 (PPO) prescription drug coverage features an annual drug deductible of $615. For generic medications, the plan offers significant savings with no copay for Tier 1 preferred generics and Tier 2 generics when filled through preferred pharmacies or preferred mail order. If you utilize 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 brand-name and specialty drugs, cost-sharing is based on coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 24% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs both carry a 25% coinsurance across all pharmacy and mail order channels. This straightforward percentage-based cost structure helps you easily project your out-of-pocket costs for higher-tier prescriptions.
Additional Benefits
The Aetna Medicare Prime (PPO) plan offers comprehensive medical coverage with predictable costs, featuring no coinsurance for inpatient hospital stays, outpatient services, and emergency care. Patients pay a daily copay of $407 for the first six days of acute inpatient stays, while primary care visits require a low $5 copay and specialist visits range from no copay to a $45 copay. Emergency room visits carry a $115 copay, which is waived if admitted, and urgent care is available for a $40 copay. This plan also includes essential routine benefits, offering no copay and no coinsurance for annual physicals, routine eye and hearing exams, and select preventive dental care. For additional needs, the plan features no copay for home health services and the first 20 days of skilled nursing facility care, while durable medical equipment and dialysis require up to a 20% coinsurance. There are no deductibles for vision and hearing services, which also include coverage for eyewear and prescription hearing aids.
Inpatient Hospital See details
Aetna Medicare Prime (PPO) covers inpatient hospital services with no coinsurance, requiring prior authorization and a daily copay of $407 for days 1 to 6 of acute stays and $346 for days 1 to 6 of psychiatric stays, followed by no copay for subsequent days. The benefit is partially covered, as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Aetna Medicare Prime (PPO) covers outpatient services with no coinsurance, featuring no copays for ambulatory surgical center and blood services. Outpatient hospital services require a $0 to $407 copay, observation services have a $407 copay per stay, and substance abuse sessions carry a $40 copay, all with no coinsurance.
Partial Hospitalization See details
Aetna Medicare Prime (PPO) covers partial hospitalization services with a copay of either $60.00 or $110.00 and no coinsurance. Prior authorization is required for these covered services.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by Aetna Medicare Prime (PPO), with ground and air ambulance services requiring a $295 copay and no coinsurance. For transportation, only some services are covered, but transportation to plan-approved health-related locations and any health-related locations is not covered.
Emergency Services See details
Aetna Medicare Prime (PPO) covers emergency services with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services are available for a $40 copay and no coinsurance, while worldwide emergency services are covered up to $250,000 with no coinsurance and copays ranging from $115 to $295.
Primary Care See details
Aetna Medicare Prime (PPO) covers primary care physician services with a $5 copay and no coinsurance, and specialist visits with no copay to a $45 copay and no coinsurance. Physical, occupational, speech, mental health, and psychiatric services are covered with copays ranging from $25 to $40 and no coinsurance, while chiropractic and podiatry services are not covered. Telehealth benefits are also available with a 20% coinsurance and copays up to $45, though prior authorization may be required for select services.
Preventive Services See details
Aetna Medicare Prime (PPO) partially covers preventive services, offering no copay and no coinsurance for annual physical exams, health education, and various screenings, while kidney disease education requires no copay and a 20% coinsurance. Supplemental services not covered under this plan include in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, home-based palliative care, in-home support, caregiver support, enhanced disease management, telemonitoring, home and bathroom safety devices, and counseling.
Hearing Services See details
Hearing services are partially covered by Aetna Medicare Prime (PPO) with no deductible and no coinsurance. Medicare-covered exams require a $45 copay, while annual routine exams and fitting evaluations have no copay. Up to two prescription hearing aids are covered annually with copays ranging from $0 to $1,700, but OTC hearing aids and inner ear, outer ear, or over-the-ear prescription models are not covered.
Vision Services See details
Aetna Medicare Prime (PPO) covers vision services with no deductibles and no coinsurance, offering eye exams with copays ranging from no copay to $45, including one routine exam per year with no copay up to a $50 maximum. Eyewear, including contacts and eyeglasses, is also covered with no copay up to a combined maximum benefit of $100 per year.
Dental Services See details
Aetna Medicare Prime (PPO) partially covers dental services, offering Medicare-covered dental for a $45 copay and no coinsurance, alongside select preventive services like cleanings, exams, and x-rays with no copay and no coinsurance. However, several sub-services are not covered, including fluoride, restorative care, endodontics, periodontics, prosthodontics, implants, oral surgery, and orthodontics.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by Aetna Medicare Prime (PPO) with no copay, though prior authorization is required and Part D home infusion drugs are not covered under the bundle. Medicare Part B chemotherapy, radiation, and other drugs require a 0% to 20% coinsurance, while Medicare Part B insulin is covered with a $35 copay and no coinsurance.
Dialysis Services See details
Dialysis services are covered by Aetna Medicare Prime (PPO) with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
Aetna Medicare Prime (PPO) covers durable medical equipment, prosthetics, and diabetic supplies with no copay, though prior authorization is required. Coinsurance ranges from no coinsurance up to 20% depending on the item, and diabetic supplies are limited to specified manufacturers.
Diagnostic and Radiological Services See details
Aetna Medicare Prime (PPO) covers diagnostic and radiological services, requiring prior authorization for all services. Lab services have no copay and no coinsurance, diagnostic tests range from no copay to a $45 copay with no coinsurance, and radiological services vary from no copay for diagnostic imaging to a $45 copay for X-rays and a minimum 20% coinsurance for therapeutic treatments.
Home Health Services See details
Home health services are covered by Aetna Medicare Prime (PPO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Aetna Medicare Prime (PPO) provides cardiac rehabilitation services with no coinsurance, though only some services are covered. Standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy for peripheral artery disease are not covered, with copays ranging from $15 to $20.
Skilled Nursing Facility (SNF) See details
Aetna Medicare Prime (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day hospital stay. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, though additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Aetna Medicare Prime (PPO) partially covers other services, offering a chronic illness meal benefit, annual wellness exams and screening mammography, 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.
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