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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 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 (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 $60.00. 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 $500.00 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 (PPO) plan features a $500 drug deductible before coverage begins. For Tier 1 preferred generic and Tier 2 generic medications, members pay no copay for one-, two-, or three-month supplies when using preferred pharmacies or preferred mail-order services. If utilizing standard pharmacies or standard mail order, Tier 1 copays start at $2 and Tier 2 copays start at $12 for a one-month supply. For higher-tier prescription drugs, cost-sharing is structured as coinsurance across all pharmacy and mail-order options. Tier 3 preferred brand drugs require a 22% coinsurance, while Tier 4 non-preferred drugs carry a 25% coinsurance. Tier 5 specialty drugs require a 27% coinsurance for a one-month supply at both preferred and standard pharmacies.
Additional Benefits
The Aetna Medicare Enhanced (PPO) plan offers comprehensive coverage with predictable costs, featuring no copays or coinsurance for primary care doctor visits and annual physicals. If you need specialist care, copays range from $0 to $35 with no coinsurance. For hospital stays, inpatient acute care requires a $350 daily copay for the first six days and no copay thereafter, while outpatient hospital services feature no coinsurance and copays ranging from $0 to $375. Routine dental cleanings, routine vision exams, and annual hearing exams are fully covered with no copays and no coinsurance. Emergency room visits carry a $115 copay, which is waived if you are admitted, and urgent care visits require a $40 copay. This plan helps keep healthcare affordable by eliminating coinsurance across many everyday medical, diagnostic, and preventive services.
Inpatient Hospital See details
Aetna Medicare Enhanced (PPO) covers inpatient hospital services with no coinsurance, requiring prior authorization for both acute and psychiatric stays. Acute stays have a $350 daily copay for days 1 to 6 and no copay for days 7 and beyond, while psychiatric stays have a $346 daily copay for days 1 to 6 and no copay for days 7 to 90. This benefit is partially covered, as non-Medicare-covered stays, upgrades, and additional psychiatric days are not covered.
Outpatient Services See details
Aetna Medicare Enhanced (PPO) covers outpatient services with no coinsurance, including ambulatory surgical center and blood services with no copay and no coinsurance. Outpatient hospital services require a $0 to $375 copay with no coinsurance, observation services require a $350 copay per stay with no coinsurance, and substance abuse sessions have a $35 copay with no coinsurance.
Partial Hospitalization See details
Aetna Medicare Enhanced (PPO) covers partial hospitalization services with a copay of $60.00 or $110.00 and no coinsurance. Prior authorization is required for these covered services.
Ambulance and Transportation Services See details
Aetna Medicare Enhanced (PPO) covers ground and air ambulance services with a $290 copay and no coinsurance, subject to prior authorization. Although some transportation services are covered, transportation to plan-approved health-related locations and any health-related locations are not covered.
Emergency Services See details
Aetna Medicare Enhanced (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 require a $40 copay and no coinsurance, while worldwide emergency and urgent services are covered up to a $250,000 limit with no coinsurance and copays ranging from $115 to $290 for emergency transportation.
Primary Care See details
Aetna Medicare Enhanced (PPO) offers primary care physician visits with no copay and no coinsurance, and specialist visits with a $0 to $35 copay and no coinsurance. Physical, occupational, speech, mental health, psychiatric, and opioid treatment services are covered with copays ranging from $30 to $35 and no coinsurance, while chiropractic and podiatry services are not covered. Telehealth benefits are also available with a $0 to $40 copay and 20% coinsurance.
Preventive Services See details
Preventive services are covered by Aetna Medicare Enhanced (PPO) with no copay and no coinsurance for annual physicals and screenings, while kidney disease education has no copay and a 20% coinsurance. Additional preventive services are partially covered with no copay and no coinsurance for benefits like health education and fitness, but sub-services such as in-home safety assessments, weight management, and medical nutrition therapy are not covered.
Hearing Services See details
Aetna Medicare Enhanced (PPO) partially covers hearing services, offering routine hearing exams and fitting evaluations once per year with no copay and no coinsurance, and Medicare-covered exams for a $35 copay and no coinsurance. Prescription hearing aids are covered up to twice annually with no coinsurance and copays ranging from $0 to $1,700, though OTC hearing aids and inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
Aetna Medicare Enhanced (PPO) covers vision services with no deductibles and no coinsurance, featuring no copay for routine eye exams and eyewear. Medicare-covered eye exams have a copay of $0 to $35, with annual maximum benefits of $50 for exams and $150 for eyewear.
Dental Services See details
Aetna Medicare Enhanced (PPO) partially covers dental services, offering Medicare-covered dental care for a $35 copay and no coinsurance. Preventive services including oral exams, cleanings, and dental X-rays are covered with no copay and no coinsurance, but fluoride, restorative, endodontic, and orthodontic services are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Aetna Medicare Enhanced (PPO) with no copay, though prior authorization is 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 a coinsurance ranging from 0% to 20%.
Dialysis Services See details
Dialysis services are covered by Aetna Medicare Enhanced (PPO) with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
Aetna Medicare Enhanced (PPO) covers medical equipment, including durable medical equipment, prosthetics, and diabetic supplies, with no copay and coinsurance ranging from no coinsurance to 20%. Prior authorization is required for these benefits, and diabetic supplies may be limited to specified manufacturers.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Aetna Medicare Enhanced (PPO), featuring no coinsurance for diagnostic services, no copay for lab services, and copays from $0 to $35 for diagnostic tests. Outpatient x-rays require a $35 copay with coinsurance, while therapeutic radiology has a minimum 20% coinsurance and diagnostic radiology copays start at $0.
Home Health Services See details
Home Health Services are covered under the Aetna Medicare Enhanced (PPO) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered with no coinsurance under the Aetna Medicare Enhanced (PPO), though only some services are covered. Standard cardiac rehabilitation, intensive cardiac rehabilitation, and supervised exercise therapy for peripheral artery disease are not covered and carry a $20 copay, while pulmonary rehabilitation is not covered and carries a $15 copay.
Skilled Nursing Facility (SNF) See details
Aetna Medicare Enhanced (PPO) covers skilled nursing facility (SNF) services with no coinsurance, offering no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, and while a prior three-day inpatient hospital stay is not required, additional days beyond the standard 100-day Medicare benefit are not covered.
Other Services See details
Other Services are partially covered under the Aetna Medicare Enhanced (PPO) plan, featuring no copay and no coinsurance for 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 these benefits.
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