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Aetna Medicare Essential (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aetna Medicare Essential (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Aetna Medicare Essential (PPO) in 2025, please refer to our full plan details page.
Aetna Medicare Essential (PPO) is a PPO plan offered by CVS Health Corporation available for enrollment in 2025 to people living in IN Central. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Aetna Medicare Essential (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 Essential (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 Essential (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $62.00. 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 $590.00 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 $10100.00 (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 $10100.00 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 Essential (PPO) plan has a $590 deductible for prescription drugs. After you meet your deductible, you will pay a copay or coinsurance for your prescriptions depending on the drug tier and where you get your prescription filled. For preferred generic drugs, there is no copay at preferred pharmacies and preferred mail order, and a $12 copay at standard pharmacies and standard mail order. You will pay 22% coinsurance for standard generic drugs, and 25% coinsurance for preferred brand and non-preferred drugs. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Aetna Medicare Essential (PPO) plan offers a range of benefits with varying costs. For inpatient hospital stays, you'll pay a copay for the first few days, but no copay for the majority of your stay. Outpatient services often have a copay, while many preventive services have no copay. This plan includes coverage for primary care, specialist visits, and mental health services with copays. Additional benefits include hearing and vision services, with copays for exams and coverage for eyewear and hearing aids. Dental services, home health, and skilled nursing facilities are also covered, with specific copays or coinsurance depending on the service.
Inpatient Hospital See details
The Aetna Medicare Essential (PPO) plan covers Inpatient Hospital services, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, you'll pay a $380 copay for days 1-7 and no copay for days 8-90. For Inpatient Hospital Psychiatric, you'll pay a $290 copay for days 1-7 and no copay for days 8-90. Additional days for Inpatient Hospital-Acute are covered with no copay, while Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute are not covered, and Additional days and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
The Aetna Medicare Essential (PPO) plan covers outpatient services including hospital services with a copay of $0 to $380, observation services with a $380 copay, and ambulatory surgical center services with no copay. The plan also covers outpatient substance abuse services with a $75 copay for both individual and group sessions and outpatient blood services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Aetna Medicare Essential (PPO) plan, with a $75 copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Aetna Medicare Essential (PPO) plan, with prior authorization required for all ambulance services. Ground ambulance services have a $280 copay, while air ambulance services have a 20% coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including Urgently Needed Services and Worldwide Emergency Services, are covered by the Aetna Medicare Essential (PPO) plan. Emergency Services have a $125 copay, Urgently Needed Services have a $40 copay, and Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $125 copay, while Worldwide Emergency Transportation has a $280 copay. Worldwide Emergency Services have a maximum benefit of $100,000.
Primary Care See details
The Aetna Medicare Essential (PPO) plan covers primary care services with no copay, chiropractic services with a $15 copay, and occupational therapy services with a $30 copay. The plan also covers physician specialist services and physical therapy/speech-language pathology services with a $30 copay. Mental health specialty services, psychiatric services, and opioid treatment program services have a $45 copay for individual and group sessions. Additional telehealth benefits are covered with a 20% coinsurance and a copay between $0-$75. Podiatry services are not covered.
Preventive Services See details
The Aetna Medicare Essential (PPO) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services include Health Education, Wigs for Hair Loss Related to Chemotherapy, Nutritional/Dietary Benefits, Additional Sessions of Smoking and Tobacco Cessation Counseling, Fitness Benefit, Remote Access Technologies, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit, all with no copay. Kidney Disease Education Services have a 20% coinsurance. In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Enhanced Disease Management, Telemonitoring Services, Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered.
Hearing Services See details
Hearing Services include hearing exams, routine hearing exams, fitting/evaluation for hearing aids, prescription hearing aids, and OTC hearing aids. Hearing exams have a $30 copay, routine hearing exams and fitting/evaluation for hearing aids have no copay, and prescription hearing aids have a $1,000 maximum plan benefit coverage per year. Prescription hearing aids - Inner Ear, Prescription Hearing Aids - Outer Ear, OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams and eyewear. Eye exams have a copay of $0-$30, with routine eye exams and other eye exam services both having no copay. Eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades, have no copay, with a combined maximum benefit of $250 per year.
Dental Services See details
Dental services with the Aetna Medicare Essential (PPO) plan include coverage for Medicare dental services with a $30 copay, oral exams with no copay, dental x-rays with no copay, and prophylaxis (cleaning) with no copay. Orthodontic services are covered up to a maximum of $3500 per year. Fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Aetna Medicare Essential (PPO) plan, but require prior authorization. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered, but require prior authorization. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits are covered, including Durable Medical Equipment (DME) with 0% to 20% coinsurance, Prosthetics/Medical Supplies with coinsurance for Medicare-covered items, and Diabetic Equipment with varying copays and coinsurance depending on the specific service. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including all diagnostic services and radiological services. Diagnostic Procedures/Tests have a copay of $0-$100, Lab Services have no copay, Diagnostic Radiological Services have a copay of at most $275, Therapeutic Radiological Services have a coinsurance of at most 20%, and Outpatient X-Ray Services have a copay of $10.
Home Health Services See details
Home health services are covered by the Aetna Medicare Essential (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. This benefit requires authorization.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover the listed sub-services. The plan has a copay for some Cardiac Rehabilitation Services, but the specific amount is not listed.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Aetna Medicare Essential (PPO) plan. There is no copay for days 1-20, and a $214 copay for days 21-100.
Other Services See details
Other Services include Over-the-Counter (OTC) Items and Meal Benefits with no copay, and Other 1 and Other 2 services with no copay. Acupuncture, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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