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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.
This summary reflects 2026 plan information. Where this plan continues in 2027, the full plan details page links to its 2027 benefits and costs.
Aetna Medicare Enhanced (PPO) is a PPO plan offered by Aetna Life Insurance Company available for the 2026 plan year to people living in San Diego County. 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 $59.00. 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 that applies only to drugs in certain tiers. You pay this amount toward covered prescriptions in those tiers before the plan's cost sharing begins; drugs in the other tiers are not subject to the deductible. See the full plan details page for the tier table.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $5500.00 for in-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $5500.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
This plan has a Maximum Out-Of-Pocket cost of $8900.00 (in-network and out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $8900.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
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 Enhanced Alternative drug benefit with a $615.00 prescription drug deductible. After meeting this deductible, you will pay no copay for Tier 1 preferred generic drugs at preferred retail pharmacies or through preferred mail order, while standard pharmacies and mail options carry a $12.00 copay. Tier 2 standard generic drugs require a 24% coinsurance across all pharmacy and mail-order options. For Tier 3 preferred brand and Tier 4 non-preferred drugs, you will pay a 25% coinsurance regardless of the pharmacy network used. Once your out-of-pocket drug costs reach $2,100.00, you enter the catastrophic coverage phase and pay nothing for covered Part D drugs. Additionally, the standard Part D premium of $45.00 is reduced to $33.00 for individuals who qualify for the low-income subsidy.
Additional Benefits
The Aetna Medicare Enhanced (PPO) plan offers robust medical coverage with no copay for primary care visits and preventive services, while specialist visits require a copay ranging from $15 to $40. Inpatient hospital stays feature a $300 daily copay for the first seven days and no copay thereafter, while emergency room visits carry a $130 copay that is waived if you are admitted. Outpatient hospital services require a copay up to $300, and skilled nursing facility stays have a $10 daily copay for the first 20 days. For routine care, this plan provides excellent value with no copay or coinsurance for home health services, routine eye exams, and annual dental cleanings. Hearing benefits include prescription hearing aids covered up to $1,250 per ear with no copay, and members receive a $30 quarterly allowance for over-the-counter wellness items. However, some services like non-emergency transportation and cardiac rehabilitation are not covered under this plan.
Inpatient Hospital See details
Aetna Medicare Enhanced (PPO) offers partially covered inpatient hospital benefits with a $300 daily copay for days 1 through 7, no copay for days 8 through 90, and no coinsurance. 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 outpatient hospital services with a $0 to $300 copay and observation services with a $300 copay. Additionally, there is no copay for ambulatory surgical center and blood services, and a $40 copay for outpatient substance abuse sessions.
Partial Hospitalization See details
Partial hospitalization benefits are covered by Aetna Medicare Enhanced (PPO) with a copay of $70 or $145 and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are partially covered by Aetna Medicare Enhanced (PPO), as transportation to plan-approved or any health-related locations is not covered. Covered ground ambulance services require a $265 copay and no coinsurance, while air ambulance services have a 20% coinsurance and no copay, with prior authorization required for both.
Emergency Services See details
Aetna Medicare Enhanced (PPO) covers emergency services with a $130 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 and transportation services are covered with copays between $130 and $265 and no coinsurance up to a $250,000 maximum limit.
Primary Care See details
Primary care benefits are partially covered by Aetna Medicare Enhanced (PPO), with podiatry services and routine chiropractic care not covered. Primary care physician visits have no copay and no coinsurance, while specialist and therapy services require copays ranging from $15 to $40 and no coinsurance. Telehealth benefits are also covered with a 20% coinsurance and copays ranging from no copay to $40.
Preventive Services See details
Aetna Medicare Enhanced (PPO) partially covers preventive services with no copay and no coinsurance for most benefits—such as annual physical exams and fitness programs—though kidney disease education requires a 20% coinsurance and no copay. Services not covered under this plan include in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge 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 modifications, and counseling.
Hearing Services See details
Hearing services are partially covered by Aetna Medicare Enhanced (PPO), offering routine exams, fitting evaluations, and prescription hearing aids with no copay or coinsurance. While prescription hearing aids are covered up to $1,250 per ear annually, OTC hearing aids and specific prescription types (inner ear, outer ear, and over the ear) are not covered.
Vision Services See details
Vision services are covered by Aetna Medicare Enhanced (PPO) with no copay, no coinsurance, and no deductible for both eye exams and eyewear. The plan offers up to a $50 annual maximum for eye exams, including one routine exam per year, and a $200 annual combined maximum for eyewear such as contacts and eyeglasses.
Dental Services See details
Dental services are partially covered by Aetna Medicare Enhanced (PPO), offering oral exams, cleanings, and x-rays with no copay and no coinsurance, and Medicare dental services for a $35 copay with no coinsurance. Other covered benefits, including restorative, endodontic, periodontic, prosthodontic, and oral surgery services, require 20% to 50% coinsurance with no copay, while fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Aetna Medicare Enhanced (PPO) covers home infusion bundled services with prior authorization, requiring a $35 copay and no coinsurance for Medicare Part B insulin. Other covered Part B chemotherapy, radiation, and specialty drugs require 0% to 20% coinsurance and no copay.
Dialysis Services See details
Dialysis services are covered under the Aetna Medicare Enhanced (PPO) plan with a 20% coinsurance and no copay. Prior authorization is required for these services.
Medical Equipment See details
Medical Equipment is covered by Aetna Medicare Enhanced (PPO), requiring prior authorization for durable medical equipment, prosthetics, medical supplies, and diabetic equipment. Covered items feature no copay, with coinsurance ranging from no coinsurance to 20% for durable medical equipment, medical supplies, and diabetic supplies, a flat 20% coinsurance for prosthetic devices, and no coinsurance for diabetic therapeutic shoes and inserts.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Aetna Medicare Enhanced (PPO) with prior authorization required. Lab services require no copay or coinsurance, diagnostic tests have a $0 to $40 copay and no coinsurance, outpatient X-rays require a $40 copay and no coinsurance, diagnostic radiology has a $0 to $295 copay with no coinsurance, and therapeutic radiology requires a 20% coinsurance with no copay.
Home Health Services See details
Aetna Medicare Enhanced (PPO) covers Home Health Services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Aetna Medicare Enhanced (PPO) plan, as all associated sub-services—including cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation—are excluded from coverage.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are partially covered by Aetna Medicare Enhanced (PPO), requiring prior authorization and featuring a $10 daily copay for days 1 to 20 and a $218 daily copay for days 21 to 100, with no coinsurance. Additional days beyond those covered by Medicare are not covered by this plan.
Other Services See details
Other Services are partially covered by Aetna Medicare Enhanced (PPO), offering no copay and no coinsurance for over-the-counter (OTC) items up to $30 every three months, annual wellness exams, screening mammography, and additional gFOBT and FIT. Acupuncture, meal benefits, and Dual Eligible SNPs with Highly Integrated Services are not covered under this plan.
Plan Providers
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, Health Care Service Corporation, HealthSpringSM, HealthSun, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
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1-877-649-2073 / TTY 711. Call-center hours (ET): Mon-Fri 8am-10pm; Sat 9am-8pm; Sun closed.
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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
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