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Aetna Medicare Prime Value (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare Prime Value (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 Value (PPO) in 2025, please refer to our full plan details page.
Aetna Medicare Prime Value (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 Value (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 Value (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 Value (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 $450.00 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:
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Drug Coverage
The Aetna Medicare Prime Value (PPO) plan has a $450 deductible for prescription drugs. Once you meet your deductible, you will pay a copay or coinsurance for your medications depending on the drug tier and pharmacy you use. For preferred generic drugs, you will have no copay at preferred pharmacies or through mail order. For standard generic drugs, you will pay 22% coinsurance. For preferred brand drugs, you will pay 25% coinsurance.
Additional Benefits
The Aetna Medicare Prime Value (PPO) plan offers a range of benefits with varying cost-sharing. For inpatient hospital stays, you'll pay a copay, but outpatient services and many preventive services come with no copay. The plan also covers hearing, vision, and dental services, with copays for some services and no copays for others, with an annual maximum for dental services. This plan covers emergency services, primary care, and home health services with no copay. Ambulance services and some other services have a copay. Diagnostic and radiological services are covered with varying copays and coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits, including acute and psychiatric care, are covered. For acute care, you will pay a $325 copay for days 1-5, and no copay for days 6-90. For psychiatric care, you will pay a $339 copay for days 1-6, and no copay for days 7-90. Additional days for inpatient hospital psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a copay between $0 and $350, Observation Services with a $325 copay, Ambulatory Surgical Center (ASC) Services with no copay, Individual and Group Sessions for Outpatient Substance Abuse with a copay of $40, and Outpatient Blood Services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Aetna Medicare Prime Value (PPO) plan, with a $60 copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Aetna Medicare Prime Value (PPO) plan. Both ground and air ambulance services have a $300 copay, with no coinsurance. 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 Value (PPO) plan. Emergency Services have a $110 copay, Urgently Needed Services have a $45 copay, and Worldwide Emergency Coverage and Urgent Coverage have a $110 copay, while Worldwide Emergency Transportation has a $300 copay.
Primary Care See details
The Aetna Medicare Prime Value (PPO) plan covers primary care physician services with no copay. Chiropractic services have a $15 copay, while occupational therapy services have a $20 copay. Physician specialist services have a copay between $0 and $30, and physical therapy and speech-language pathology services have a $20 copay. Mental health specialty services, psychiatric services, and opioid treatment program services have a $40 copay for individual and group sessions. Additional telehealth benefits are covered with a 20% coinsurance and a copay between $0 and $45.
Preventive Services See details
Preventive Services include an annual physical exam with no copay, and additional services that are covered, including Health Education, Nutritional/Dietary Benefit, Additional Sessions of Smoking and Tobacco Cessation Counseling, Fitness Benefit, Remote Access Technologies, Wigs for Hair Loss Related to Chemotherapy, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit, all with no copay. Kidney Disease Education Services are covered with a 20% coinsurance.
Hearing Services See details
Hearing exams are covered under the Aetna Medicare Prime Value (PPO) plan with a $30 copay, and routine hearing exams and fitting/evaluation for hearing aids have no copay. Prescription hearing aids are partially covered, while OTC hearing aids, and some prescription hearing aid sub-services are not covered.
Vision Services See details
Vision Services include coverage for eye exams, with a copay between $0 and $30, and eyewear, with no copay and a combined maximum plan benefit of $150 per year for both in-network and out-of-network services. Routine eye exams are covered with no copay for one visit every year, while other eye exam services, including follow-up diabetic eye exams, are covered with no copay. Contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered with no copay.
Dental Services See details
Dental services include coverage for Medicare dental services with a $30 copay, and other services are also covered. 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. There is a maximum benefit of $1250 per year for both in-network and out-of-network services.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with 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 under the Aetna Medicare Prime Value (PPO) plan, but require prior authorization. You will pay a 20% coinsurance for these services.
Medical Equipment See details
The Aetna Medicare Prime Value (PPO) plan covers Durable Medical Equipment (DME) with a coinsurance between 0% and 20%, but does not cover DME for use outside the home. Prosthetics, Medical Supplies, and Diabetic Equipment are also covered, with coinsurance ranging from 0% to 20% depending on the specific service.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services, diagnostic procedures/tests with a copay between $0 and $30, and lab services with no copay. Radiological Services include coverage for diagnostic radiological services with a copay up to $200, therapeutic radiological services with 20% coinsurance, and outpatient X-ray services with a $30 copay.
Home Health Services See details
Home Health Services are covered by the Aetna Medicare Prime Value (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 not covered by the Aetna Medicare Prime Value (PPO) plan. The plan does not cover any of the sub-services, including Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Aetna Medicare Prime Value (PPO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $125 per day; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The "Other Services" benefit for Aetna Medicare Prime Value (PPO) covers a meal benefit with no copay and other services, including annual wellness exams and screening mammography, and gFOBT and FIT with no copay. 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, and self-directed personal assistance services are not covered.
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