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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.
Aetna Medicare Enhanced (PPO) is a PPO plan offered by CVS Health Corporation available for enrollment in 2025 to people living in Santa Barbara 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 $74.00. 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. 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 $8900.00 (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 $8900.00 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 Enhanced (PPO) plan features an annual prescription drug deductible of $615.00 before coverage begins. Under this plan, Tier 1 preferred generic drugs have no copay at preferred pharmacies or through preferred mail order, though standard options charge a $12.00 copay. For Tier 2 standard generic drugs, members pay a 24% coinsurance across all pharmacy types. Tier 3 preferred brand drugs and Tier 4 non-preferred drugs both carry a 25% coinsurance for all pharmacy and mail-order methods. After your annual out-of-pocket drug costs reach $2,100.00, you will pay nothing for Medicare Part D covered drugs during the catastrophic coverage phase. Additionally, the standard Part D premium is $36.20, which can be reduced to $24.20 for individuals qualifying for the full low-income subsidy.
Additional Benefits
The Aetna Medicare Enhanced (PPO) plan features no copay and no coinsurance for primary care doctor visits, routine preventive screenings, and home health services. For inpatient hospital stays, members pay a 445 dollar daily copay for the first five to six days, while emergency care carries a 130 dollar copay that is waived if admitted. Outpatient services generally require no coinsurance, with copays ranging from no copay up to 425 dollars depending on the service. Essential wellness benefits like vision and dental care are well-supported, offering no copay or coinsurance for routine eye exams, eyewear up to a 200 dollar allowance, and preventive dental cleanings. Prescription hearing aids are also covered with no copay up to 1,250 dollars per ear annually. However, members should note that certain benefits, such as routine chiropractic care, cardiac rehabilitation, and over-the-counter items, are not covered under this plan.
Inpatient Hospital See details
Aetna Medicare Enhanced (PPO) covers inpatient acute hospital stays with a $445 daily copay for days 1 to 6 and no copay for days 7 to 90, and psychiatric stays with a $445 daily copay for days 1 to 5 and no copay for days 6 to 90, with no coinsurance required for either service. This benefit is partially covered because upgrades, non-Medicare-covered stays, and additional days for psychiatric hospitalizations are not covered.
Outpatient Services See details
Outpatient services are covered by Aetna Medicare Enhanced (PPO) with no coinsurance, featuring copays ranging from $0 to $425 for outpatient hospital services and a $445 copay per stay for observation services. Patients will pay a $40 copay for outpatient substance abuse sessions, while ambulatory surgical center and outpatient blood services are covered with no copay.
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 services.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are partially covered by Aetna Medicare Enhanced (PPO), as transportation services to health-related locations are not covered. Covered ground ambulance services require a $295 copay and no coinsurance, while air ambulance services require 20% coinsurance and no copay, both requiring prior authorization.
Emergency Services See details
Aetna Medicare Enhanced (PPO) covers emergency services with a $130 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $40 copay and no coinsurance, while worldwide emergency services are covered up to a $250,000 limit with copays ranging from $130 to $295.
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. Patients pay no copay and no coinsurance for primary care physician visits, while other covered services require copays ranging from $15 to $40 with no coinsurance, and telehealth services require a 20% coinsurance and a $0 to $40 copay.
Preventive Services See details
Preventive Services are partially covered under the Aetna Medicare Enhanced (PPO) plan, offering no copay and no coinsurance for annual physicals, health education, and most screenings. Kidney disease education is covered with a 20% coinsurance and no copay, while several sub-services like weight management and therapeutic massage are not covered.
Hearing Services See details
Hearing services are partially covered by Aetna Medicare Enhanced (PPO), which offers annual routine exams and fitting evaluations with no copay or coinsurance. Prescription hearing aids (all types) are covered with no copay or coinsurance up to $1,250 per ear annually, but OTC hearing aids and inner ear, outer ear, and over-the-ear prescription aids are not covered.
Vision Services See details
Vision services are covered by Aetna Medicare Enhanced (PPO) with no copay, no coinsurance, and no deductible for eye exams and eyewear. Members are covered for a $50 annual maximum for eye exams and a $200 annual combined allowance for eyewear, including contacts and eyeglasses.
Dental Services See details
Dental services are partially covered by Aetna Medicare Enhanced (PPO), excluding fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics. Preventive care like exams, x-rays, and cleanings has no copay and no coinsurance, while Medicare-covered dental services require a $35 copay and no coinsurance. Other covered comprehensive services require no copay and a 20% to 50% coinsurance, up to a $1,000 annual maximum.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered under the Aetna Medicare Enhanced (PPO) plan with prior authorization required. Medicare Part B insulin drugs require a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs have no copay and coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Aetna Medicare Enhanced (PPO) covers dialysis services with a 20% coinsurance and no copay. Prior authorization is required for these services.
Medical Equipment See details
Aetna Medicare Enhanced (PPO) covers medical equipment, including durable medical equipment, prosthetics, medical supplies, and diabetic equipment, though prior authorization is required. There is no copay for these services, and coinsurance ranges from no coinsurance up to 20% depending on the item.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Aetna Medicare Enhanced (PPO), with prior authorization required for both. Lab services have no copay or coinsurance, outpatient X-rays carry a $40 copay with no coinsurance, diagnostic tests and radiological services have copays ranging from $0 to $40 and $0 to $295 with no coinsurance, and therapeutic radiological services require a 20% coinsurance.
Home Health Services See details
Aetna Medicare Enhanced (PPO) covers home health services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under Aetna Medicare Enhanced (PPO), as no coverage, copays, or coinsurance are provided for cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation.
Skilled Nursing Facility (SNF) See details
Aetna Medicare Enhanced (PPO) partially covers Skilled Nursing Facility (SNF) services, which require a $10 daily copay for days 1 to 20 and a $218 daily copay for days 21 to 100, with no coinsurance. Prior authorization is required, and while a 3-day prior inpatient hospital stay is not necessary, additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other services are partially covered by Aetna Medicare Enhanced (PPO), including annual wellness exams, screening mammography, and extra gFOBT and FIT tests with no copay and no coinsurance. Acupuncture, over-the-counter items, meal benefits, and Dual Eligible SNPs with highly integrated services are not covered.
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