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Aetna Medicare Elite (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare Elite (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Aetna Medicare Elite (PPO) in 2026, please refer to our full plan details page.
Aetna Medicare Elite (PPO) is a PPO plan offered by CVS Health Corporation available for enrollment in 2025 to people living in Greater Rochester Area. This plan received an overall rating of 4.5 out of 5 stars in 2026.
It's important to know that Aetna Medicare Elite (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 Elite (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 Elite (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $84.00. 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 has a $1250.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
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 Elite (PPO) plan has an annual prescription drug deductible of $615. You will pay no copay for Tier 1 preferred generic and Tier 2 generic drugs when using a preferred pharmacy or preferred mail order. If you use standard pharmacies or standard mail order, Tier 1 copays start at $2.00 and Tier 2 copays start at $12.00 for a one-month supply. For brand-name and specialty medications, the plan charges coinsurance instead of flat copays. Tier 3 preferred brand drugs require 24% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs both require 25% coinsurance. Coinsurance rates remain the same whether you use preferred or standard pharmacies, though specialty drugs are limited to a one-month supply.
Additional Benefits
The Aetna Medicare Elite (PPO) plan offers comprehensive coverage with no copay and no coinsurance for primary care visits, preventive services, and routine dental, vision, and hearing exams. For specialized care, specialist visits range from no copay to a $45 copay, while inpatient hospital stays require a $399 daily copay for the first six days of acute care followed by no copay for days seven through ninety. Outpatient services and diagnostic tests are also highly accessible, featuring low to no copays and no coinsurance for most services. Emergency care is covered with a $115 copay, which is waived upon hospital admission, while urgently needed services require a $40 copay. Members pay no copay and no coinsurance for home health care, while medical equipment and dialysis require no copay but carry up to a twenty percent coinsurance. While this plan provides extensive coverage for daily medical needs, certain services such as cardiac rehabilitation and routine podiatry are not covered.
Inpatient Hospital See details
Inpatient hospital services are covered by Aetna Medicare Elite (PPO) with no coinsurance, requiring a daily copay of $399 for days 1 to 6 of acute care and $346 for days 1 to 6 of psychiatric care, followed by no copay for days 7 to 90. This benefit is partially covered, as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Aetna Medicare Elite (PPO) covers outpatient services with no coinsurance, offering ambulatory surgical center and blood services with no copay and no coinsurance. Outpatient hospital services have a $0 to $399 copay and no coinsurance, observation services require a $399 copay per stay with no coinsurance, and substance abuse sessions have a $45 copay and no coinsurance.
Partial Hospitalization See details
Aetna Medicare Elite (PPO) covers partial hospitalization services with a copay of $105.00 or $110.00 and no coinsurance. Prior authorization is required for these covered services.
Ambulance and Transportation Services See details
Aetna Medicare Elite (PPO) covers ground and air ambulance services with a $295 copay and no coinsurance, though prior authorization is required. While transportation services are listed as covered, trips to plan-approved or any other health-related locations are not covered.
Emergency Services See details
Aetna Medicare Elite (PPO) covers emergency services with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours, and urgently needed services with a $40 copay and no coinsurance. Worldwide emergency, urgent, and transportation services are also covered up to a $250,000 maximum with no coinsurance and copays ranging from $115 to $295.
Primary Care See details
Aetna Medicare Elite (PPO) covers primary care visits with no copay and no coinsurance, and specialist visits with a $0 to $45 copay and no coinsurance. Therapy and mental health services require copays of $30 to $45 with no coinsurance, while telehealth has a $0 to $45 copay and 20% coinsurance. Podiatry is not covered, and for chiropractic care, some services are covered but routine and other chiropractic services are not covered.
Preventive Services See details
Preventive Services are partially covered by Aetna Medicare Elite (PPO), featuring no copay and no coinsurance for annual exams, screenings, and select supplements, though kidney education carries a 20% coinsurance and no copay. Non-covered sub-services include in-home safety assessments, PERS, medical nutrition therapy, medication reconciliation, re-admission prevention, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, disease management, telemonitoring, home safety devices, and counseling.
Hearing Services See details
Aetna Medicare Elite (PPO) hearing services feature no coinsurance, offering annual routine hearing exams and fitting evaluations with no copay, and Medicare-covered exams for a $45 copay. Prescription hearing aids are partially covered with copays ranging from $0 to $1,700 for up to two aids per year, while inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
Aetna Medicare Elite (PPO) covers vision services with no deductibles and no coinsurance, featuring eye exams with copays ranging from no copay to $45 and eyewear with no copay. Routine eye exams (one per year) and eyewear—including contacts, lenses, and frames—are subject to annual maximum benefits of $50 and $100, respectively.
Dental Services See details
Dental services are partially covered under the Aetna Medicare Elite (PPO) plan, which features a $45 copay and no coinsurance for Medicare-covered dental services, and no copay and no coinsurance for routine exams, cleanings, and x-rays. Non-covered services include fluoride, restorative services, endodontics, periodontics, prosthodontics, implants, and oral surgery.
Home Infusion bundled Services See details
Aetna Medicare Elite (PPO) covers home infusion bundled services with no copay and no coinsurance, though prior authorization is required. Under this benefit, Medicare Part B chemotherapy and other drugs carry a 0% to 20% coinsurance with no copay, while Part B insulin drugs are covered with a $35 copay and no coinsurance.
Dialysis Services See details
Dialysis services are covered by Aetna Medicare Elite (PPO) with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
Aetna Medicare Elite (PPO) covers medical equipment with no copay, though prior authorization is required for these services. Members will pay between no coinsurance and 20% coinsurance for durable medical equipment, medical supplies, and diabetic supplies, and a flat 20% coinsurance for prosthetic devices and diabetic therapeutic shoes or inserts.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Aetna Medicare Elite (PPO) and require prior authorization. Diagnostic tests carry a $0 to $45 copay with no coinsurance, lab services and diagnostic radiology have no copay or coinsurance, and therapeutic radiology requires a minimum 20% coinsurance, while outpatient X-rays require a $45 copay and coinsurance.
Home Health Services See details
Home Health Services are covered under the Aetna Medicare Elite (PPO) 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 Elite (PPO) plan, as key sub-services like cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation are not covered. While there is no coinsurance, these services carry copayments ranging from $15 to $20.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Aetna Medicare Elite (PPO) with no coinsurance, featuring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, a prior three-day hospital stay is not needed, and additional days beyond the standard 100 days are not covered.
Other Services See details
Aetna Medicare Elite (PPO) partially covers other services, providing a meal benefit for chronic illness, an annual wellness exam and screening mammography, and additional gFOBT and FIT screenings with no copay and no coinsurance. Acupuncture, over-the-counter (OTC) items, and Dual Eligible SNPs are not covered under this plan.
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