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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 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 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 $131.00. 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 Enhanced (PPO) plan features an annual drug deductible of $615. Under this plan, you will enjoy no copay for Tier 1 (Preferred Generic) and Tier 2 (Generic) medications when using a preferred pharmacy or preferred mail order service. If you choose standard pharmacies or standard mail order, Tier 1 drugs carry a copay starting at $2.00, while Tier 2 drugs start at a $12.00 copay for a one-month supply. For brand-name and specialty prescriptions, costs are determined by coinsurance across both preferred and standard networks. 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. Specialty medications are limited to a one-month supply, whereas other tiers offer flexible multi-month filling options.
Additional Benefits
The Aetna Medicare Enhanced (PPO) plan offers robust coverage for essential medical services, often with no copayments or coinsurance. You will pay no copay and no coinsurance for primary care physician visits, while specialist visits feature copays ranging from no copay to $45. For hospital care, inpatient stays require a $399 daily copay for the first six days and no copay thereafter, while emergency room visits carry a $115 copay with no coinsurance. This plan also includes valuable supplemental coverage, such as dental services up to a $1,000 annual maximum and vision care with no copay for eyewear up to $100 annually. Routine hearing exams are available with no copay, and prescription hearing aids carry copays ranging from $0 to $1,700. Additionally, home health care is covered with no copay or coinsurance, and skilled nursing facility stays require no copay for the first 20 days.
Inpatient Hospital See details
Aetna Medicare Enhanced (PPO) covers inpatient acute hospital stays with no coinsurance, requiring a $399 daily copay for days 1 to 6 and no copay for days 7 and beyond. Inpatient psychiatric stays are also covered with no coinsurance and a $346 daily copay for days 1 to 6, though upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services are covered by the Aetna Medicare Enhanced (PPO) with no coinsurance, featuring no copays for ambulatory surgical center and blood services. Outpatient hospital services require a copay of $0 to $399, observation services carry a $399 copay per stay, and outpatient substance abuse sessions have a $45 copay, with prior authorization required for most services.
Partial Hospitalization See details
Partial hospitalization is covered under the Aetna Medicare Enhanced (PPO) plan with a copay of $80.00 or $110.00 and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Aetna Medicare Enhanced (PPO) offers partial coverage for ambulance and transportation services, featuring a $295 copay and no coinsurance for prior-authorized ground and air ambulance services. Transportation services to plan-approved or any health-related locations are not covered under this plan.
Emergency Services See details
Aetna Medicare Enhanced (PPO) covers emergency services with a $115 copay and no coinsurance, which is waived if admitted to the hospital within 24 hours, and urgently needed services with a $40 copay and no coinsurance. Worldwide emergency and urgent care are also covered with a $115 copay, and worldwide emergency transportation carries a $295 copay, all with no coinsurance up to a $250,000 maximum plan benefit.
Primary Care See details
Aetna Medicare Enhanced (PPO) offers primary care physician services with no copay and no coinsurance, and specialist visits with a copay ranging from no copay to $45 and no coinsurance. Most other covered services, such as physical therapy ($30 copay) and mental health services ($45 copay), require no coinsurance, though 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 the Aetna Medicare Enhanced (PPO), offering no copay and no coinsurance for annual physicals, health education, and glaucoma screenings, though kidney disease education requires a 20% coinsurance and no copay. Several supplemental services are not covered under this plan, including in-home safety assessments, personal emergency response systems, medical nutrition therapy, and weight management programs.
Hearing Services See details
Aetna Medicare Enhanced (PPO) hearing services are partially covered, offering Medicare-covered exams for a $45 copay and no coinsurance, alongside annual routine exams and fitting evaluations for no copay and no coinsurance. 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 models are not covered.
Vision Services See details
Aetna Medicare Enhanced (PPO) covers vision services with no deductibles and no coinsurance, featuring eye exams with a $0 to $45 copay and a $50 annual maximum. Eyewear, including lenses, frames, and contacts, is covered with no copay up to a combined annual maximum of $100.
Dental Services See details
Dental services are partially covered by Aetna Medicare Enhanced (PPO) up to a $1,000 annual maximum for both in-network and out-of-network care. Medicare-covered dental services require a $45 copay and no coinsurance, while other covered preventive and comprehensive services have no copay and no coinsurance, excluding maxillofacial prosthetics, implant services, and orthodontics which are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered under the Aetna Medicare Enhanced (PPO) with no copay, though prior authorization is required. Under this plan, Medicare Part B insulin drugs have a $35 copay and no coinsurance, while chemotherapy, radiation, and other Medicare Part B drugs require a coinsurance between 0% and 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 these covered services.
Medical Equipment See details
Aetna Medicare Enhanced (PPO) covers medical equipment, including durable medical equipment, prosthetics, and diabetic supplies, with no copay and prior authorization required. Depending on the specific item, costs range from no coinsurance up to 20% coinsurance, with diabetic supplies limited to specified manufacturers.
Diagnostic and Radiological Services See details
Aetna Medicare Enhanced (PPO) covers diagnostic services with no coinsurance, featuring no copay for lab services and a $0 to $45 copay for diagnostic procedures. Covered radiological services include diagnostic radiology with no copay, outpatient X-rays with a $45 copay, and therapeutic radiology with a minimum 20% coinsurance.
Home Health Services See details
Aetna Medicare Enhanced (PPO) covers Home Health Services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Aetna Medicare Enhanced (PPO) covers some cardiac rehabilitation services with no copay and no coinsurance, but several key services are not covered. Specifically, standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) are not covered under this plan.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) care is partially covered by Aetna Medicare Enhanced (PPO) with no coinsurance, featuring no copay for days 1 to 20 and a $218 daily copay for days 21 to 100. Prior authorization is required, a prior three-day hospital stay is not needed, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other Services are partially covered by the Aetna Medicare Enhanced (PPO) plan, which features a meal benefit for chronic illnesses, annual wellness exams, screening mammographies, and additional gFOBT and FIT with no copay and no coinsurance. Acupuncture, over-the-counter (OTC) items, and highly integrated dual-eligible SNP services are not covered under this plan.
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