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Aetna Medicare Premier (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare Premier (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Aetna Medicare Premier (PPO) in 2025, please refer to our full plan details page.
Aetna Medicare Premier (PPO) is a PPO plan offered by CVS Health Corporation available for enrollment in 2025 to people living in Central Upstate NY 2. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Aetna Medicare Premier (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 Premier (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 Premier (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $36.00. 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 $590.00 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 Premier (PPO) plan has an "Enhanced Alternative" drug benefit. The plan has a deductible of $590.00. In the initial coverage phase, after you meet your deductible, you will pay either a copay or coinsurance depending on the drug tier and pharmacy. For example, you will pay no copay for preferred generic drugs at a preferred pharmacy. You will pay 22% coinsurance for standard generic drugs at any pharmacy.
Additional Benefits
The Aetna Medicare Premier (PPO) plan offers a range of benefits, including inpatient hospital care with a copay, outpatient services with varying copays, and coverage for emergency and urgent care services both domestically and worldwide. The plan also includes coverage for primary care, preventive services with no copays for annual physical exams, and hearing and vision services, such as eye exams and eyewear, and dental services including oral exams and x-rays. Additionally, the plan provides coverage for home health services with no copay, skilled nursing facility stays with a copay, and medical equipment with coinsurance. However, some services are not covered, such as acupuncture, over-the-counter items, and certain other services.
Inpatient Hospital See details
Inpatient Hospital coverage includes acute and psychiatric care, with a copay of $375 for days 1-6 and no copay for days 7-90 for acute care, and a copay of $339 for days 1-6 and no copay for days 7-90 for psychiatric care. Additional days for inpatient hospital-acute are covered, but non-Medicare-covered stays and upgrades for inpatient hospital-acute are not covered, and additional days and non-Medicare-covered stays for inpatient hospital psychiatric are also not covered.
Outpatient Services See details
Outpatient Services are covered by the Aetna Medicare Premier (PPO) plan, including outpatient hospital services with a copay between $0 and $300, observation services with a $375 copay, and outpatient substance abuse services with a $40 copay for both individual and group sessions. Ambulatory Surgical Center (ASC) Services and Outpatient Blood Services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Aetna Medicare Premier (PPO) plan, but requires prior authorization. The copay for this benefit is $80.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by Aetna Medicare Premier (PPO), with prior authorization required for all ambulance services. Ground and Air Ambulance Services have a $300 copay, and there is no coinsurance; however, Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Aetna Medicare Premier (PPO) plan. Emergency Services have a $110 copay, and Urgently Needed Services have a $45 copay; both have no coinsurance. Worldwide Emergency Coverage and Worldwide Urgent Coverage each have a $110 copay, while Worldwide Emergency Transportation has a $300 copay; all three have no coinsurance.
Primary Care See details
The Aetna Medicare Premier (PPO) plan covers primary care physician services with a $5 copay and specialist services with a $40 copay. Chiropractic services have a $15 copay, while occupational therapy services have a $35 copay. Physical therapy and speech-language pathology services have a $40 copay. Other health care professionals have a copay ranging from $0 to $40. Individual and group sessions for mental health and psychiatric services have a $40 copay. Additional telehealth benefits have a 20% coinsurance and a copay between $0 and $45. Opioid treatment program services have a $40 copay. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
The Aetna Medicare Premier (PPO) plan covers preventive services, including annual physical exams with no copay. Additional preventive services like Health Education, Nutritional/Dietary Benefit, Additional Sessions of Smoking and Tobacco Cessation Counseling, Fitness Benefit, and Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline) may have a copay. The plan also covers Kidney Disease Education Services with a 20% coinsurance, and other preventive services like Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit with no copay.
Hearing Services See details
Hearing services include hearing exams with a $40 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids (all types) are covered with a maximum copay of $1700, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision services are covered, including eye exams and eyewear. Eye exams have a copay of $0-$40, and routine eye exams and other eye exam services have no copay. Eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades, are covered with a combined maximum plan benefit of $150 per year, and have no copay.
Dental Services See details
The Aetna Medicare Premier (PPO) plan covers some dental services, including oral exams, dental x-rays, and prophylaxis (cleaning). Oral exams and dental x-rays have no copay, while Medicare dental services have a $40 copay. Fluoride treatment, orthodontic services, and other services are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered under the Aetna Medicare Premier (PPO) plan, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay, while 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 Premier (PPO) plan, but require prior authorization. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical equipment, including durable medical equipment, prosthetics, medical supplies, and diabetic equipment, is covered. Durable medical equipment has a coinsurance between 0% and 20%, while durable medical equipment for use outside the home is not covered. Prosthetic devices and diabetic therapeutic shoes/inserts have a 20% coinsurance, and medical supplies and diabetic supplies have a coinsurance between 0% and 20%.
Diagnostic and Radiological Services See details
Aetna Medicare Premier (PPO) covers Diagnostic and Radiological Services, including Diagnostic Procedures/Tests with a copay between $0 and $40, Lab Services with no copay, Diagnostic Radiological Services with a copay up to $250, Therapeutic Radiological Services with a coinsurance of at least 20%, and Outpatient X-Ray Services with a $40 copay. All services require prior authorization.
Home Health Services See details
Home Health Services are covered by the Aetna Medicare Premier (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 covered by the Aetna Medicare Premier (PPO) plan, but the specific services are not covered. The plan has a copay, but the exact amount is not specified in the provided details.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Aetna Medicare Premier (PPO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214 per day. Additional days beyond Medicare-covered SNF stays and non-Medicare-covered SNF stays are not covered.
Other Services See details
The Aetna Medicare Premier (PPO) plan does not cover 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. The plan covers meal benefits with no copay, and also covers Other 1 and Other 2 services with no copay.
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