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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 Alameda, Sacramento, San Francisco & Yolo Counties. 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 $63.00. 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 $5900.00 for in-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $5900.00 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 annual prescription drug deductible of $615.00 before initial coverage benefits begin. During the initial coverage phase, you will have no copay for Tier 1 preferred generic drugs when using a preferred pharmacy or preferred mail order, while standard pharmacies and mail orders carry a $12.00 copay. Tier 2 standard generic drugs require a 24% coinsurance, while Tier 3 preferred brand and Tier 4 non-preferred drugs both require a 25% coinsurance. These cost-sharing rates apply until your yearly out-of-pocket drug expenses reach $2,100.00. Once this threshold is met, you enter the catastrophic coverage phase and will pay nothing for covered Medicare Part D prescription drugs. Additionally, beneficiaries who qualify for the low-income subsidy can see their Part D premium reduced from $12.90 to $0.90.
Additional Benefits
The Aetna Medicare Enhanced (PPO) plan offers robust medical coverage with no copays or coinsurance for primary care visits, home health services, and most preventive care options. For hospital stays, members pay a daily copay of $300 for the first seven days of inpatient care and no copay for days eight through 90, with no coinsurance required. Emergency room visits carry a $130 copay, while specialist visits require a copay between $15 and $40. This plan also includes essential dental, vision, and hearing benefits to help reduce your out-of-pocket expenses. Routine dental cleanings, annual eye exams, and hearing tests are available with no copays or coinsurance, alongside allowances of up to $200 for eyewear and $1,250 for prescription hearing aids. Additionally, members receive a $30 quarterly allowance for over-the-counter health items, though some specialized services like cardiac rehabilitation are not covered.
Inpatient Hospital See details
Aetna Medicare Enhanced (PPO) partially covers inpatient hospital services with no coinsurance, requiring a $300 daily copay for days 1 through 7 and no copay for days 8 through 90. Prior authorization is required, and while unlimited additional acute days are covered at no copay, 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 across all benefits. Outpatient hospital services carry a copay of $0 to $300, observation services require a $300 copay per stay, and outpatient substance abuse sessions have a $40 copay. Ambulatory surgical center and outpatient blood services are provided with no copay.
Partial Hospitalization See details
Aetna Medicare Enhanced (PPO) covers partial hospitalization benefits with a copay of either $70 or $145 and no coinsurance. Prior authorization is required for these covered services.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are partially covered by the Aetna Medicare Enhanced (PPO) plan, as transportation services to plan-approved or any health-related locations are not covered. Covered ground ambulance services require a $285 copay and no coinsurance, while air ambulance services require no copay and a 20% coinsurance.
Emergency Services See details
Aetna Medicare Enhanced (PPO) covers emergency services with a $130 copay, which is waived if admitted to the hospital within 24 hours, and urgently needed services with a $40 copay, with no coinsurance required for either. Worldwide emergency services, urgent care, and emergency transportation are also covered up to a $250,000 limit, featuring copays of $130, $130, and $285, respectively, and no coinsurance.
Primary Care See details
Aetna Medicare Enhanced (PPO) provides partially covered Primary Care benefits with no copay and no coinsurance for primary care visits, while specialist and therapy visits require copays between $15 and $40 with no coinsurance. Podiatry and routine chiropractic services are not covered, and telehealth services carry a 20% coinsurance with a $0 to $40 copay.
Preventive Services See details
Aetna Medicare Enhanced (PPO) partially covers preventive services, offering most benefits, such as annual physical exams and health education, with no copay and no coinsurance. Kidney disease education services are covered with a 20% coinsurance and no copay. However, sub-services like 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 are not covered.
Hearing Services See details
Aetna Medicare Enhanced (PPO) partially covers hearing services, offering annual routine exams and fitting evaluations with no copay, coinsurance, or deductible. Prescription hearing aids are covered with no copay up to a $1,250 annual maximum, but 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 Enhanced (PPO) with no copays or coinsurance for both eye exams and eyewear. The plan provides up to a $50 annual maximum for eye exams, including one routine exam, and a $200 yearly allowance for contact lenses, eyeglasses, and upgrades.
Dental Services See details
Aetna Medicare Enhanced (PPO) partially covers dental services, excluding fluoride treatments, maxillofacial prosthetics, implant services, and orthodontics. Preventive care like exams, cleanings, and x-rays has no copay and no coinsurance, while Medicare-covered dental services require a $30 copay and no coinsurance. Other covered dental services, such as restorative and endodontic care, have a 20% to 50% coinsurance and no copay, subject to a $1,000 annual maximum.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered under Aetna Medicare Enhanced (PPO), requiring prior authorization and offering Medicare Part B insulin with a $35 copay and no coinsurance. Chemotherapy, radiation, and other Part B drugs have no copay and range from no coinsurance up to 20% coinsurance.
Dialysis Services See details
Aetna Medicare Enhanced (PPO) covers dialysis services with a 20% coinsurance and no copay. Prior authorization is required for this benefit.
Medical Equipment See details
Aetna Medicare Enhanced (PPO) covers medical equipment, including durable medical equipment, prosthetics, and diabetic supplies, with prior authorization required. Members pay no copay for diabetic therapeutic shoes and inserts, while coinsurance ranges from no coinsurance up to 20% for other equipment and supplies.
Diagnostic and Radiological Services See details
Aetna Medicare Enhanced (PPO) covers diagnostic and radiological services, with prior authorization required for these benefits. Diagnostic procedures, lab services, and outpatient X-rays have no copay and no coinsurance, while diagnostic radiological services carry a copay of $0 to $250 (no coinsurance) and therapeutic radiological services require 20% coinsurance (no copay).
Home Health Services See details
Home health services are covered under the Aetna Medicare Enhanced (PPO) plan 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 none of the sub-services are covered in practice. Because these services—including cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation—are not covered, there are no copay or coinsurance benefits available.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are partially covered by Aetna Medicare Enhanced (PPO), as additional days beyond Medicare-covered stays are not covered. For covered SNF stays, which require prior authorization, you will pay no coinsurance alongside daily copays of $10 for days 1 to 20 and $218 for days 21 to 100.
Other Services See details
Other Services are partially covered by Aetna Medicare Enhanced (PPO) with no copay and no coinsurance for covered options, which include annual wellness exams, screening mammographies, additional gFOBT and FIT screenings, and up to $30 every three months for over-the-counter (OTC) items. Acupuncture, meal benefits, and dual eligible SNPs with highly integrated services are not covered.
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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