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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 Metro: Staten Island. 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 $0.00. 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 $1000.00 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 features an annual prescription drug deductible of $615. For Tier 1 preferred generics and Tier 2 generics, you will pay no copay when using a preferred pharmacy or preferred mail-order service. If you choose a standard pharmacy or standard mail-order service, Tier 1 copays range from $2 to $6, while Tier 2 copays range from $12 to $36 depending on the supply duration. Higher-tier medications require percentage-based cost sharing instead of flat copays. Tier 3 preferred brands carry a 24% coinsurance across all pharmacy and mail-order options. Tier 4 non-preferred drugs and Tier 5 specialty drugs both require 25% coinsurance, with specialty medications restricted to a one-month supply.
Additional Benefits
The Aetna Medicare Elite (PPO) plan offers comprehensive coverage for core medical needs, featuring a $5 copay for primary care visits and specialist copays ranging from no copay up to $45, with no coinsurance. Emergency care is accessible with a $115 copay, while inpatient hospital stays require a daily copay for the first six days followed by no copay for subsequent days. Outpatient hospital services and diagnostic lab tests are also covered with no coinsurance and variable copays starting at no copay. Routine preventive care, annual physicals, and home health services are covered with no copay and no coinsurance. Vision and dental benefits include routine exams and cleanings with no copay, though specialized treatments and prescription hearing aids require copayments. Overall, this plan minimizes out-of-pocket costs by offering many essential and preventive services with no coinsurance and no copay.
Inpatient Hospital See details
Inpatient hospital services are covered by Aetna Medicare Elite (PPO) with no coinsurance, though prior authorization is required. Acute stays require a $407 daily copay for days 1 to 6 followed by no copay for days 7 and beyond, while psychiatric stays require a $346 daily copay for days 1 to 6 and no copay for days 7 to 90. The 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 no copay for ambulatory surgical center and blood services. Outpatient hospital services require a $0 to $407 copay, observation services cost a $407 copay per stay, and outpatient substance abuse sessions carry a $45 copay.
Partial Hospitalization See details
Aetna Medicare Elite (PPO) covers partial hospitalization benefits with a copay of $105.00 or $110.00 and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
Ambulance services under the Aetna Medicare Elite (PPO) are covered with a $275 copay and no coinsurance for both ground and air transportation, with prior authorization required. Routine transportation services to plan-approved or any health-related locations are not covered.
Emergency Services See details
Emergency services are covered by Aetna Medicare Elite (PPO) 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 services are covered up to a $250,000 maximum with no coinsurance and copays of $115 for emergency or urgent care and $275 for emergency transportation.
Primary Care See details
Aetna Medicare Elite (PPO) covers primary care physician services with a $5 copay and specialist visits with a range of no copay to a $45 copay, both with no coinsurance. Physical, occupational, speech, psychiatric, and mental health therapies are covered with copays ranging from $35 to $45 and no coinsurance, while telehealth services require a 20% coinsurance and chiropractic and podiatry services are not covered.
Preventive Services See details
Aetna Medicare Elite (PPO) preventive services are partially covered, offering an annual physical exam, health education, and select screenings with no copay and no coinsurance, while kidney disease education is covered with no copay and a 20% coinsurance. Supplemental services such as in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, disease management, telemonitoring, home safety modifications, and counseling are not covered.
Hearing Services See details
Aetna Medicare Elite (PPO) covers hearing services with no coinsurance, featuring a $45 copay for Medicare-covered exams and no copay for annual routine exams and fitting evaluations. Prescription hearing aids are partially covered with no coinsurance and copays ranging from $0 to $1,700 for up to two aids per year, though OTC hearing aids and inner ear, outer ear, and over-the-ear prescription models are not covered.
Vision Services See details
Vision services are covered by Aetna Medicare Elite (PPO) with no deductibles and no coinsurance, offering eye exams with a copay of $0 to $45 and one routine exam per year with no copay up to a $50 maximum. Covered eyewear, including contacts and eyeglasses, is available with no copay up to a $150 combined annual maximum.
Dental Services See details
Aetna Medicare Elite (PPO) partially covers dental services, offering Medicare-covered dental care for a $45 copay and no coinsurance, alongside preventive cleanings, exams, and x-rays with no copay and no coinsurance. Sub-services that are not covered under this plan include fluoride, restorative services, endodontics, periodontics, prosthodontics, implants, oral surgery, and orthodontics.
Home Infusion bundled Services See details
Aetna Medicare Elite (PPO) covers home infusion bundled services 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 and other Part B drugs require no copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Aetna Medicare Elite (PPO) plan with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
Aetna Medicare Elite (PPO) covers medical equipment with no copay, though prior authorization is required and diabetic supplies are limited to specified manufacturers. Durable medical equipment, medical supplies, and diabetic supplies carry a coinsurance ranging from no coinsurance up to 20%, while prosthetic devices and diabetic therapeutic shoes or inserts require 20% coinsurance.
Diagnostic and Radiological Services See details
Aetna Medicare Elite (PPO) covers diagnostic and radiological services, offering lab services and diagnostic radiology with no copay and no coinsurance. Diagnostic tests range from a $0 to $45 copay, outpatient x-rays require a $45 copay, and therapeutic radiology incurs a 20% coinsurance, with prior authorization required.
Home Health Services See details
Home health services are covered under the Aetna Medicare Elite (PPO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by Aetna Medicare Elite (PPO) with no coinsurance. Members pay a $20 copay for cardiac, intensive cardiac, and supervised exercise therapy (SET) for peripheral artery disease (PAD) services, and a $15 copay for pulmonary rehabilitation services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) care is 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, and additional days beyond the standard 100-day Medicare limit are not covered.
Other Services See details
Aetna Medicare Elite (PPO) partially covers other services, offering a meal benefit, annual wellness exams and screening mammographies, and additional gFOBT and FIT tests with no copay and no coinsurance. Acupuncture and over-the-counter (OTC) items are not covered under these services.
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