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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 Central Upstate NY 2. 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 $56.00. 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 (PPO) plan features an annual prescription drug deductible of $615. For Tier 1 preferred generic and Tier 2 generic medications, members enjoy no copay when using preferred pharmacies or preferred mail order services. If you choose standard pharmacies or standard mail order options, Tier 1 copays start at $2 and Tier 2 copays start at $12 for a one-month supply. For brand-name and specialty medications, your costs are based on coinsurance across all pharmacy and mail order types. Tier 3 preferred brand drugs require a 24% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs both carry a 25% coinsurance. These clear pricing tiers help you manage your out-of-pocket prescription costs throughout the year.
Additional Benefits
The Aetna Medicare Enhanced (PPO) plan provides comprehensive coverage with affordable out-of-pocket costs, including no copays and no coinsurance for primary care visits, annual physicals, routine vision exams, and home health services. Specialist visits, urgent care, and Medicare-covered dental and hearing exams are available for a flat $40 copay. Inpatient hospital stays feature no coinsurance, though acute stays require a $399 copay for the first six days and psychiatric stays require a $346 copay for the first six days, with no copays for subsequent days. For supplemental care, the plan offers routine dental cleanings and routine hearing exams with no copay, alongside up to $150 in covered eyewear and hearing aid coverage with copays up to $1,700. Emergency services carry a $115 copay, which is waived if admitted, while ambulance rides require a $300 copay. Additionally, diagnostic labs and home infusion services feature no copays, while medical equipment and dialysis require up to 20% coinsurance.
Inpatient Hospital See details
Aetna Medicare Enhanced (PPO) partially covers inpatient hospital services with no coinsurance, requiring prior authorization for both acute and psychiatric stays. Acute stays carry a $399 copay for days 1-6 and no copay for days 7 and beyond, while psychiatric stays require a $346 copay for days 1-6 and no copay for days 7-90; however, upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Aetna Medicare Enhanced (PPO) covers outpatient services with no coinsurance, including no copays for ambulatory surgical center and outpatient blood services. Outpatient hospital services require a copay of $0 to $399, observation services have a $399 copay per stay, and outpatient substance abuse sessions have a $40 copay, with prior authorization required for most of these services.
Partial Hospitalization See details
Aetna Medicare Enhanced (PPO) covers partial hospitalization services with a copay of $105.00 or $110.00 and no coinsurance. Prior authorization is required for these covered benefits.
Ambulance and Transportation Services See details
Aetna Medicare Enhanced (PPO) covers Medicare-approved ground and air ambulance services with a $300 copay and no coinsurance, subject to prior authorization. While some transportation services are covered, transportation to plan-approved health-related locations and any other health-related locations is not covered.
Emergency Services See details
Aetna Medicare Enhanced (PPO) covers emergency services with a $115 copay, which is waived if you are admitted to the hospital within 24 hours, and urgently needed services with a $40 copay, both featuring no coinsurance. Worldwide emergency and urgent care are also covered with a $115 copay, while worldwide emergency transportation has a $300 copay, all with no coinsurance up to a $250,000 maximum lifetime limit.
Primary Care See details
Primary care benefits under the Aetna Medicare Enhanced (PPO) feature primary care physician visits with no copay and no coinsurance, and specialist visits for a $40 copay and no coinsurance. Physical, occupational, and mental health therapies are covered with copays ranging from $35 to $40 and no coinsurance, while podiatry is not covered and some chiropractic services are covered but routine and other chiropractic services are not.
Preventive Services See details
Preventive services are partially covered by Aetna Medicare Enhanced (PPO), offering no copay and no coinsurance for annual physical exams, health education, and select screenings, while kidney disease education requires a 20% coinsurance and no copay. Multiple supplemental services, such as personal emergency response systems, weight management programs, and nutritional therapy, are not covered.
Hearing Services See details
Aetna Medicare Enhanced (PPO) hearing services are partially covered with no deductible, featuring a $40 copay and no coinsurance for Medicare-covered exams, and no copay or coinsurance for annual routine exams and fittings. Prescription hearing aids are covered with no coinsurance and copays ranging from $0 to $1,700, but OTC hearing aids and inner ear, outer ear, or over-the-ear prescription hearing aids are not covered.
Vision Services See details
Aetna Medicare Enhanced (PPO) covers vision services with no deductible and no coinsurance, offering routine eye exams with no copay and Medicare-covered exams with a copay of up to $40. Covered eyewear, including contacts and eyeglasses, also features no copay and is subject to a combined $150 annual maximum benefit.
Dental Services See details
Aetna Medicare Enhanced (PPO) partially covers dental services, offering Medicare-covered dental services for a $40 copay with no coinsurance, and routine exams, cleanings, and x-rays with no copay and no coinsurance. However, several services are not covered, including fluoride, restorative, orthodontic, endodontic, periodontic, prosthodontic, implant, and oral surgery services.
Home Infusion bundled Services See details
Aetna Medicare Enhanced (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Under this plan, Medicare Part B insulin drugs require a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs are covered with no copay and a coinsurance of 0% to 20%.
Dialysis Services See details
Dialysis Services are covered under the Aetna Medicare Enhanced (PPO) plan with no copay and a 20% coinsurance. Prior authorization is required to receive coverage for these services.
Medical Equipment See details
Aetna Medicare Enhanced (PPO) covers medical equipment, including durable medical equipment (DME), prosthetics, and diabetic supplies, with no copays and required prior authorization. Coinsurance ranges from no coinsurance up to 20% for DME, medical supplies, and diabetic supplies, while prosthetic devices and diabetic therapeutic shoes or inserts require a flat 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under Aetna Medicare Enhanced (PPO) with prior authorization required. Lab services have no copay or coinsurance, diagnostic tests carry a $0 to $40 copay with no coinsurance, outpatient X-rays require a $40 copay and coinsurance, and therapeutic radiological services require a copay and a minimum 20% coinsurance.
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 not covered under the Aetna Medicare Enhanced (PPO) plan, as major sub-services such as intensive cardiac, pulmonary, and SET for PAD rehabilitation are not covered in practice. For any covered services, there is no coinsurance, but copayments range from $15 to $20.
Skilled Nursing Facility (SNF) See details
Skilled nursing facility (SNF) services are partially covered by Aetna Medicare Enhanced (PPO) with no coinsurance, requiring prior authorization but no prior three-day hospital stay. There is no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, though additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Aetna Medicare Enhanced (PPO) partially covers other services, offering a meal benefit for chronic illness, annual wellness exams, screening mammography, and additional gFOBT and FIT screenings with no copay and no coinsurance. Acupuncture, over-the-counter (OTC) items, and dual-eligible SNP services are not covered.
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