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Aetna Medicare Enhanced Advantage (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare Enhanced Advantage (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 Advantage (PPO) in 2026, please refer to our full plan details page.
Aetna Medicare Enhanced Advantage (PPO) is a PPO plan offered by CVS Health Corporation available for enrollment in 2025 to people living in SNJ Counties: ATL, BUR, CAM, CPM, CUM, GLO, ON. This plan received an overall rating of 4.5 out of 5 stars in 2026.
It's important to know that Aetna Medicare Enhanced Advantage (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 Advantage (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 Advantage (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $91.00. 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 $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 Enhanced Advantage (PPO) prescription drug plan features an annual drug deductible of $615. For generic medications, members enjoy no copay on Tier 1 (Preferred Generic) and Tier 2 (Generic) drugs when using preferred pharmacies or preferred mail-order services. Standard pharmacies and standard mail order are also available with low copayments starting at $2 for Tier 1 and $12 for Tier 2 one-month supplies. For higher-tier medications, costs are based on coinsurance rather than flat copays. Tier 3 (Preferred Brand) drugs require a 24% coinsurance, while Tier 4 (Non-Preferred Drug) and Tier 5 (Specialty Tier) drugs require 25% coinsurance across all pharmacy types. Specialty Tier medications are limited to a one-month supply under this plan.
Additional Benefits
The Aetna Medicare Enhanced Advantage (PPO) plan offers robust coverage with predictable out-of-pocket costs, featuring no copays for primary care doctor visits, home health services, and preventive care. For hospital stays, members pay a daily copay for the first six days of inpatient care and no coinsurance, while emergency room visits carry a flat $115 copay. Specialist visits, diagnostic tests, and outpatient services are also highly accessible, with low copays ranging up to $35 and no coinsurance for most services. This plan also includes valuable supplemental benefits, providing routine dental care and annual vision and hearing exams with no copay. Prescription hearing aids are covered with copays up to $1,700, and members receive a $150 annual eyewear allowance and up to $1,000 in annual dental benefits. Other essential services, such as skilled nursing care and medical equipment, are covered with no coinsurance and standard daily copays or up to 20% coinsurance.
Inpatient Hospital See details
Aetna Medicare Enhanced Advantage (PPO) covers inpatient hospital services with no coinsurance, requiring a $395 daily copay for days 1 to 6 of acute stays and a $346 daily copay for days 1 to 6 of psychiatric stays, with no copay for subsequent covered days. While unlimited additional acute days are covered with no copay, this benefit is only partially covered as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Aetna Medicare Enhanced Advantage (PPO) covers outpatient services with no coinsurance, including outpatient hospital services with a $0 to $350 copay and observation services with a $395 copay per stay. Ambulatory surgical center and outpatient blood services require no copay and no coinsurance, while outpatient substance abuse sessions have a $35 copay and no coinsurance.
Partial Hospitalization See details
Aetna Medicare Enhanced Advantage (PPO) covers partial hospitalization benefits with a copay of either $60.00 or $110.00 and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by Aetna Medicare Enhanced Advantage (PPO), with ground and air ambulance services requiring a $290 copay and no coinsurance. While some transportation services are covered, trips to plan-approved health-related locations and any other health-related locations are not covered.
Emergency Services See details
Emergency services are covered by Aetna Medicare Enhanced Advantage (PPO) with a $115 copay (waived if admitted within 24 hours) and no coinsurance, while urgent care requires a $40 copay and no coinsurance. Worldwide emergency and urgent services are also covered with a $115 copay ($290 for transportation) and no coinsurance, up to a $250,000 plan limit.
Primary Care See details
Primary care is partially covered by Aetna Medicare Enhanced Advantage (PPO), as podiatry and chiropractic services are not covered. Covered primary care physician visits have no copay and no coinsurance, while specialists, therapies, and mental health services range from a $0 to $35 copay with no coinsurance. Telehealth benefits are also available with a $0 to $40 copay and 20% coinsurance.
Preventive Services See details
Aetna Medicare Enhanced Advantage (PPO) covers preventive services with no copay and no coinsurance for most benefits, including annual physical exams, glaucoma screenings, and diabetes self-management training, while kidney disease education requires a 20% coinsurance and no copay. This benefit is partially covered because several supplemental services, such as medical nutrition therapy, weight management programs, and in-home safety assessments, are not covered.
Hearing Services See details
Hearing services under the Aetna Medicare Enhanced Advantage (PPO) are partially covered with no deductible, offering Medicare-covered exams for a $35 copay and no coinsurance, alongside annual routine exams and fittings with no copay and no coinsurance. Up to two prescription hearing aids are covered annually with no coinsurance and copays up to $1,700, though inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
Vision services are covered by Aetna Medicare Enhanced Advantage (PPO) with no deductibles and no coinsurance, featuring a $0 to $35 copay for eye exams and no copay for eyewear. Routine eye exams are limited to one per year, and a combined $150 annual maximum benefit applies to all covered eyewear, including contacts, frames, lenses, and upgrades.
Dental Services See details
Aetna Medicare Enhanced Advantage (PPO) offers partially covered dental services with no copay and no coinsurance for most preventive and comprehensive care up to a $1,000 annual maximum, though maxillofacial prosthetics, implant services, and orthodontics are not covered. Medicare-covered dental services are also available under the plan with a $35 copay and no coinsurance.
Home Infusion bundled Services See details
Aetna Medicare Enhanced Advantage (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Under this benefit, covered Part B chemotherapy and other Part B drugs carry a coinsurance of 0% to 20%, while covered Part B insulin drugs require a $35 copay and no coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Aetna Medicare Enhanced Advantage (PPO) with no copay and a 20% coinsurance. Prior authorization is required to receive this benefit.
Medical Equipment See details
Aetna Medicare Enhanced Advantage (PPO) covers medical equipment, including durable medical equipment (DME), prosthetics, medical supplies, and diabetic equipment, with no copay and prior authorization required. Coinsurance ranges from no coinsurance to 20% depending on the specific equipment or supply.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by the Aetna Medicare Enhanced Advantage (PPO) plan, requiring prior authorization. Diagnostic procedures and tests have no coinsurance and copays from $0 to $35, lab services have no copay, and radiological services range from a $0 minimum copay for diagnostic imaging to a $35 copay for X-rays and a minimum 20% coinsurance for therapeutic services.
Home Health Services See details
Home Health Services are covered by Aetna Medicare Enhanced Advantage (PPO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under the Aetna Medicare Enhanced Advantage (PPO) with no coinsurance, though only some services are covered. Specifically, cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered, carrying copayments ranging from $15 to $20.
Skilled Nursing Facility (SNF) See details
Aetna Medicare Enhanced Advantage (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day hospital stay. This benefit is partially covered, offering no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, while additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Aetna Medicare Enhanced Advantage (PPO) partially covers other services with no copay and no coinsurance, which includes a chronic illness meal benefit, annual wellness exams, screening mammographies, and additional gFOBT and FIT. Acupuncture and over-the-counter (OTC) items are not covered under this benefit.
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