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Aetna Medicare Primary (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare Primary (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Aetna Medicare Primary (PPO) in 2025, please refer to our full plan details page.
Aetna Medicare Primary (PPO) is a PPO plan offered by CVS Health Corporation available for enrollment in 2025 to people living in South Carolina metro areas. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Aetna Medicare Primary (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 Primary (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 Primary (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 does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $7750.00 (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 $7750.00 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 Primary (PPO) plan has an "Enhanced Alternative" drug benefit. This plan has a $0 deductible, meaning you pay nothing out-of-pocket before your drug coverage begins. In the initial coverage phase, you'll pay a $5 copay for preferred generic drugs at preferred and mail-order pharmacies, and $12 at standard pharmacies. For other tiers, you will pay coinsurance ranging from 25% to 35%. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Aetna Medicare Primary (PPO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay, while outpatient services, including substance abuse and blood services, have copays. Emergency services have a copay, and primary care, including primary care physician services, has no copay. Preventive services, such as annual physical exams, are covered with no copay. Hearing services include hearing exams and hearing aids, with a maximum benefit, and vision services cover eye exams and eyewear. Dental services, including exams and x-rays, are covered with no copay up to an annual maximum. The plan also covers home infusion, dialysis, medical equipment, diagnostic services, home health, cardiac rehabilitation, and skilled nursing facilities with varying cost-sharing amounts.
Inpatient Hospital See details
Inpatient Hospital benefits are covered by the Aetna Medicare Primary (PPO) plan, with Inpatient Hospital-Acute services requiring a $299 copay for days 1-10 and no copay for days 11-90, while Inpatient Hospital Psychiatric services require a $286 copay for days 1-8 and no copay for days 9-90. Additional days for Inpatient Hospital-Acute are covered with no copay, but Non-Medicare-covered stays and Upgrades for Inpatient Hospital-Acute are not covered. Additional days and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are also not covered.
Outpatient Services See details
Outpatient services include coverage for outpatient hospital services with a copay between $0 and $299, observation services with a $299 copay, ambulatory surgical center services with no copay, outpatient substance abuse services with a $40 copay for both individual and group sessions, and outpatient blood services with no copay. Prior authorization is required for some services.
Partial Hospitalization See details
Partial Hospitalization is covered under the Aetna Medicare Primary (PPO) plan, but requires prior authorization. You will have a $105 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the Aetna Medicare Primary (PPO) plan. Ground ambulance services have a $275 copay, while air ambulance services have a 20% coinsurance. Transportation services to a plan-approved health-related location and any health-related location are not covered.
Emergency Services See details
Emergency Services are covered by the Aetna Medicare Primary (PPO) plan, with a $125 copay for emergency services and a $50 copay for urgently needed services, with no coinsurance. Worldwide Emergency Services are also covered, with a $125 copay for Worldwide Emergency and Urgent Coverage, and a $275 copay for Worldwide Emergency Transportation, with no coinsurance.
Primary Care See details
Primary Care Physician Services are covered with no copay. Chiropractic Services are covered with a $20 copay, but routine care is not covered. Occupational Therapy Services are covered with a $30 copay and no coinsurance. Physician Specialist Services have a copay between $10 and $50. Mental Health Specialty Services, including individual and group sessions, have a $40 copay. Other Health Care Professional services have a copay between $0 and $50. Psychiatric Services, including individual and group sessions, have a $40 copay. Physical Therapy and Speech-Language Pathology Services have a $30 copay and no coinsurance. Additional Telehealth Benefits are covered with a 20% coinsurance and a copay between $0 and $40. Opioid Treatment Program Services have a $40 copay.
Preventive Services See details
The Aetna Medicare Primary (PPO) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services include Health Education, Wigs for Hair Loss Related to Chemotherapy, Additional Sessions of Smoking and Tobacco Cessation Counseling, Fitness Benefit, and Remote Access Technologies, all of which have no copay.
Hearing Services See details
Hearing services include hearing exams with a $50 copay, routine hearing exams with no copay, and fitting/evaluation for a hearing aid with no copay. Prescription hearing aids are covered with a maximum plan benefit of $1250 per year, but prescription hearing aids for the inner, outer, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services with the Aetna Medicare Primary (PPO) plan includes eye exams with a copay of $0-$50, and eyewear with a combined maximum plan benefit of $150 per year with no copay. Routine eye exams have no copay for 1 visit every year, and other eye exam services are covered with no copay. Contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames and upgrades are covered with no copay.
Dental Services See details
The Aetna Medicare Primary (PPO) plan covers dental services, including oral exams, dental x-rays, and other diagnostic services with no copay, as well as prophylaxis, fluoride treatments, and other preventive services with no copay. This plan has a $1,000 annual maximum for dental services. Maxillofacial Prosthetics, Implant Services and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with coinsurance between 0% and 20%. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered by the Aetna Medicare Primary (PPO) plan, but require prior authorization. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits are covered under the Aetna Medicare Primary (PPO) plan. Durable Medical Equipment (DME) has a coinsurance between 0% and 20%, and Prosthetic Devices have a 20% coinsurance; Medical Supplies have a 0% - 20% coinsurance. Diabetic Supplies have a coinsurance between 0% and 20%, and Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the Aetna Medicare Primary (PPO) plan. Diagnostic Procedures/Tests have a copay between $0 and $120, Lab Services have no copay, and Outpatient X-Ray Services have a $14 copay. Diagnostic Radiological Services have a copay up to $200 and Therapeutic Radiological Services have a coinsurance of at least 20%.
Home Health Services See details
Home Health Services are covered by the Aetna Medicare Primary (PPO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover the sub-services of 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. There is a copay for these services, but the amount is not specified.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are covered by the Aetna Medicare Primary (PPO) plan, but require prior authorization. For days 1-20, there is a $10 copay, and for days 21-100, there is a $214 copay.
Other Services See details
Under "Other Services," the Aetna Medicare Primary (PPO) plan covers over-the-counter (OTC) items with no copay, a maximum plan benefit coverage amount of $45 every three months, and offers nicotine replacement therapy and Naloxone coverage. Acupuncture, Dual Eligible SNPs, 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, 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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